Disparities in Cancer Incidence and Mortality
Among Delaware Residents, 1998–2002
June 2006
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF PUBLIC HEALTH
Health Promotion and Disease Prevention Section
This report is made possible with funding from the Delaware Health Fund and
strategic leadership and guidance provided by the Delaware Cancer Consortium.
CONTENTS
EXECUTIVE SUMMARY
1. INTRODUCTION 1
1.1. Delaware Cancer Statistics 5
1.2. Disparities in Cancer Burden 5
1.2.1. Factors That Contribute to Disparities 6
1.3. Objectives 8
2. METHODS 9
2.1. Incidence and Mortality Data 9
2.1.1. Data Sources 9
2.1.1.1. Delaware Cancer Registry 9
2.1.1.2. Surveillance, Epidemiology, and End Results Program 9
2.1.1.3. National Center for Health Statistics 10
2.1.1.4. Census Data 10
2.1.2. Variable Definitions 11
2.1.3. Analytic Methods 11
2.1.3.1. Direct Standardization 11
2.1.4. Disparities in Incidence and Mortality 12
2.1.5. Trends in Cancer Incidence and Mortality 13
2.1.6. Data Reporting Rules 13
2.2. Behavioral Cancer Risk Factors and Screening Usage 13
2.2.1. Data Sources 13
2.2.2. Variable Definitions 13
2.2.3. Analytic Methods 14
2.3. Cancer Stage at Diagnosis 15
2.3.1. Data Sources 15
2.3.2. Variable Definitions 15
2.3.3. Analytic Methods 15
2.4. Cancer Treatment 16
2.5. Data Interpretation 17
3. RESULTS 19
3.1. Cancer Incidence and Mortality 19
3.1.1. Cancer Burden in Delaware 19
3.1.2. Disparities in Cancer Incidence and Mortality 19
3.1.3. Cancer Disparities by Sex, Age, and County of Residence 24
3.1.3.1. Disparities by Sex 24
3.1.3.2. Disparities by Age 27
3.1.3.3. Disparities by County of Residence 30
3.2. Trends in Cancer Incidence and Mortality 33
3.2.1. Cancer Incidence in Delaware, 1980–2002 34
3.2.1.1. All Cancer Sites Combined 34
3.2.1.2. Female Breast Cancer 35
3.2.1.3. Colorectal Cancer 36
3.2.1.4. Lung and Bronchus Cancer 37
3.2.1.5. Prostate Cancer 38
3.2.2. Cancer Mortality in Delaware, 1980–2002 39
3.2.2.1. All Cancer Sites Combined 39
3.2.2.2. Female Breast Cancer 40
3.2.2.3. Colorectal Cancer 41
3.2.2.4. Lung and Bronchus Cancer 42
3.2.2.5. Prostate Cancer 43
3.3. Factors That Contribute to Disparities 43
3.3.1. Cancer Risk Factors and Screening Usage 44
3.3.2. Stage at Diagnosis 58
3.3.2.1. Female Breast Cancer 58
3.3.2.2. Colorectal Cancer 61
3.3.2.3. Prostate Cancer 64
3.3.3. Cancer Treatment 65
3.4. Health Policy, Health System, and Societal Factors 68
REFERENCES
APPENDIXES
A: Supplemental Information on Report Methodology
B: Supplemental Incidence and Mortality Data
C: Supplemental BRFSS Information
LIST OF TABLES
Table 1. Comparison of Delaware With the SEER Population 10
Table 2. Number of New Cancers and Deaths From Cancer in Delaware,
by Race/Ethnicity 19
Table 3. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites in Delaware and the United States 23
Table 4. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by Sex, in Delaware and the United
States 25
Table 5. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by Age, in Delaware 28
Table 6. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by County of Residence,
in Delaware 31
Table 7. Comparison of Demographic Characteristics Between Delaware and the United
States, 2002 44
Table 8. Access to Health Care in Delaware and the United States, by Race/Ethnicity 45
Table 9. Comparison of Modifiable Risk Factors for Cancer Between Delaware and the
United States, by Race/Ethnicity 47
Table 10. Comparison of the Percentage of Individuals Who Have Not Received Cancer-
Screening Tests Within the Recommended Time Interval Between Delaware
and the United States, by Race 49
Table 11. Association Between Race/Ethnicity and Access to Health Care in Delaware 51
Table 12. Multivariate Regression Model of Predictors of Lack of Access to Health Care 51
Table 13. Association Between Race/Ethnicity and Modifiable Risk Factors for Cancer in
Delaware 53
Table 14. Multivariate Regression Model of Predictors of Having Modifiable Risk Factors
for Cancer in Delaware 53
Table 15. Association Between Race and Not Receiving Cancer Screening Tests
in Delaware 56
Table 16. Multivariate Model of Predictors for Not Receiving Cancer Screening Tests in
Delaware 56
Table 17. Number and Percentage of Delaware Breast or Colorectal Cancer Patients With Local
Disease Treated for Cancer in Delaware, by Receipt of Standard / Approrpriate
Cancer Treatment 67
Table 18. Association Between Receipt of Standard Treatment and Treating Facility, Cancer
Type and Race Among Individuals with Local Stage Disease and Treated in
Delaware 67
LIST OF FIGURES
Figure 1. A model for the development of health disparities 7
Figure 2. Age-adjusted incidence rates for all cancer sites combined, Delaware and
the United States 20
Figure 3. Age-adjusted mortality rates for all cancer sites combined, Delaware and
the United States 21
Figure 4. Age-adjusted incidence rates for the four major cancer sites, by race, Delaware
and the United States 22
Figure 5. Age-adjusted mortality rates for the four major cancer sites, by race, Delaware
and the United States 23
Figure 6. Age-adjusted incidence rate differences comparing African Americans with
Whites for colorectal and lung and bronchus cancer, by sex, Delaware and the
United States 26
Figure 7. Age-adjusted mortality rate differences comparing African Americans with
Whites for colorectal and lung and bronchus cancer, by sex, Delaware and the
United States 27
Figure 8. Incidence rate differences comparing African Americans with Whites for the
four major cancers, by age, in Delaware 29
Figure 9. Mortality rate differences comparing African Americans with Whites for the four
major cancers, by age, in Delaware 30
Figure 10. Incidence rate differences comparing African Americans with Whites for the four
major cancers, by county of residence, in Delaware 32
Figure 11. Mortality rate differences comparing African Americans with Whites for the four
major cancers, by county of residence, in Delaware 33
Figure 12. Trends in cancer incidence for all sites combined comparing Whites with African
Americans, by sex, in Delaware 34
Figure 13. Trends in female breast cancer incidence comparing Whites with African
Americans, in Delaware 35
Figure 14. Trends in colorectal cancer incidence comparing Whites with African
Americans, by sex, in Delaware 36
Figure 15. Trends in lung and bronchus cancer incidence comparing Whites with African
Americans, by sex, in Delaware 37
Figure 16. Trends in prostate cancer incidence comparing Whites with African Americans,
in Delaware 38
Figure 17. Trends in cancer mortality for all sites combined comparing Whites with African
Americans, by sex, in Delaware 39
Figure 18. Trends in female breast cancer mortality comparing Whites with African
Americans, in Delaware 40
Figure 19. Trends in colorectal cancer mortality comparing Whites with African
Americans, by sex, in Delaware 41
Figure 20. Trends in lung and bronchus cancer mortality comparing Whites with African
Americans, by sex, in Delaware 42
Figure 21. Trends in prostate cancer mortality comparing Whites with African Americans,
in Delaware 43
Figure 22. Racial/ethnic disparities in access to health care in Delaware and the
United States 46
Figure 23. Racial/ethnic disparities in behavioral cancer risk factors in Delaware and
the United States 48
Figure 24. Racial disparities in cancer screening test usage in Delaware and the
United States 50
Figure 25. Percentage of female breast cancer cases, by stage at diagnosis and race,
in Delaware 58
Figure 26. Percentage of female breast cancer cases diagnosed at an advanced stage,
by race and county of residence, in Delaware 59
Figure 27. Percentage of female breast cancer cases diagnosed at an advanced stage,
by race and age at diagnosis, in Delaware 60
Figure 28. Percentage of colorectal cancer cases, by stage at diagnosis and race,
in Delaware 61
Figure 29. Percentage of colorectal cancer cases diagnosed at an advanced stage,
by race and county of residence, in Delaware 62
Figure 30. Percentage of colorectal cancer cases diagnosed at an advanced stage,
by race and age at diagnosis, in Delaware 63
Figure 31. Percentage of prostate cancer cases, by stage at diagnosis and race, in Delaware 64
Figure 32. Percentage of prostate cancer cases diagnosed at an advanced stage,
by race and county of residence, in Delaware 65
Figure 33. Percentage of prostate cancer cases diagnosed at an advanced stage,
by race and age at diagnosis, in Delaware 66
EXECUTIVE SUMMARY OF FINDINGS
CANCER INCIDENCE AND MORTALITY
The results of this investigation demonstrate that among all racial and ethnic groups in Delaware,
African Americans have disproportionately high overall cancer incidence and mortality rates.
Compared with Whites, African Americans have higher incidence rates for colorectal, lung and
bronchus, and prostate cancer. Cancer mortality rates among African Americans are higher than
those for Whites for each of the four cancer sites examined, with the greatest disparity in prostate
cancer mortality. The patterns of these disparities in incidence and mortality for cancers of the
female breast, colon, lung and bronchus, prostate, and all sites combined are consistent with the
literature based on national data.
Data trends in cancer incidence and mortality from 1980 to 2002, based on data provided by the
Delaware Cancer Registry, show that cancer incidence is decreasing among Whites for all cancer
sites examined, except that in recent years an increase in prostate cancer was observed. Among
African Americans, incidence rates are decreasing for all cancers combined, female breast, and
lung and bronchus cancer, but in recent years the incidence is increasing for colorectal and
prostate cancer.
The data show cancer mortality decreasing among all races for all cancer sites except female
breast and colorectal cancer. Mortality rates among African Americans for all cancers combined,
lung and bronchus cancer, and prostate cancer are decreasing faster than those among Whites,
narrowing the disparity over time. However, the disparity in mortality rates between African
American and White men for colorectal cancer is increasing over time.
Factors That Contribute to Disparities
The observation that the disparities in incidence, mortality, and time trends are not uniform
across cancer sites suggests that there might be disparities in modifiable behavioral risk factors,
screening, stage of disease at time of diagnosis, and treatment, which may differ by cancer site.
Using BRFS data, we investigated whether there were any notable racial/ethnic differences in
access to health care, the prevalence of modifiable cancer risk factors, and the use of screening.
The data showed that a smaller percentage of African Americans and Hispanics have health
insurance, a personal doctor, and a reliable source of medical care than Whites. It is encouraging
to note that for all three measures, minorities in Delaware have greater access to health care than
minorities in the rest of the United States.
The prevalence of modifiable behavioral cancer risk factors differed by race/ethnicity. Fewer
African Americans than Whites participated in leisure or occupational physical activity and ate
five or more fruits and vegetables per day. African Americans had a greater prevalence of
obesity than other races. Whites were the most likely to have ever smoked and chronically
consumed alcohol. Hispanics had higher rates of obesity than Whites. Education had the
strongest and most consistent impact on behavioral risk factors, with individuals with less than a
high school education more likely to be at risk. Screening behavior was most influenced by
having a personal doctor; Whites and African Americans were screened at essentially the same
rates. There were no strong associations observed between race and stage of diagnosis.
Initial analyses, limited to only Delaware Cancer Registry data for four cancers (female breast,
colorectal, lung/bronchus and prostate) diagnosed at local stage of disease, suggested that fewer
African Americans than Whites received the study-defined “standard” treatment for these
cancers. A statistically significant difference was observed for colorectal cancer. Subsequent,
refined analyses, expanded to include facility-based source data and to accommodate legitimate
reasons for lack of “standard” treatment (e.g., a patient’s decision to decline further treatment, or
the presence of co-morbid conditions precluding radiation therapy), demonstrated a statistically
significant difference only for treating facility; i.e., there was a strong association between the
treating facility and the likelihood of receiving “appropriate” treatment. This association could
be due to differences in documentation, rather than differences in practice.
Health Policy and Barriers to Care
Research reveals the impact of patient and system barriers on racial/ethnic cancer health
disparities in the United States. Patient barriers, such as poverty, lack of health insurance, and
lack of health literacy, affect the delivery of cancer prevention and treatment services received
by minorities and the medically underserved. System barriers prevent cancer services from being
provided as a continuum of care and create an inequality in the delivery of cancer care. As these
barriers continue to contribute to cancer health disparities in the United States, health care
delivery systems and Federal, State, and local agencies need to take the initiative to address these
barriers and create equality in cancer care for racial/ethnic populations.
COMPARISON OF DISPARITIES IN DELAWARE VERSUS THE UNITED STATES
Disparities in incidence in Delaware were comparable or smaller than were those in the United
States. Mortality disparities were smaller in Delaware than in the United States with the
exception of colorectal cancer; mortality rates were higher in Delaware for all cancer sites
combined and lung and bronchus cancer.
The general pattern for incidence observed in Delaware was seen in the United States; however,
the incidence of prostate cancer among African American men was increasing in Delaware,
while rates had stabilized nationally. Also, although an increase was observed in the United
States in lung and bronchus cancer among African American women, the rate among African
American women in Delaware has been declining.
Patterns in mortality rates were similar between Delaware and the United States. The disparity in
colorectal cancer mortality was widening in both Delaware and the United States. For female
breast cancer, there was a similar pattern in Delaware and the United States, although Delaware
had higher rates with less disparity. The general pattern for prostate cancer was similar over
time; less disparity was observed in Delaware, and mortality rates were lower (3–5, 9).
Based on data from the BRFS, the Delaware population had a higher percentage of African
Americans but a lower percentage of Hispanics than the national average. Educational attainment
in Delaware was comparable with national levels, while income was higher in Delaware than in
the United States for all races. On all measures of access to health care examined, Delaware
residents of all races were more likely to have access than the rest of the United States. There is,
however, greater disparity in the prevalence of behavioral risk factors between African
Americans and Whites in Delaware than in the United States. Though in Delaware we did not
find significant differences in stage at diagnosis, disparities in this area have been documented in
some studies (8). Disparities in treatment have been documented in other investigations for early
stage female breast, colorectal, and lung and bronchus cancer (32, 43–45).
CAUSES OF DISPARITY
The NIH Strategic Plan to Reduce and Ultimately Eliminate Health Disparities has three major
goals: 1) to increase minority health and disparities research, 2) to increase opportunities for
disparity research training and career development, and 3) to increase outreach to ensure that the
public, health care professionals, and communities are educated about the latest advances in
disparities research.
The development of health disparities is a complex process that involves biological, cultural,
socioeconomic, and political factors. These in turn can affect health practices, psychosocial and
environmental stress, psychosocial resources, and the medical care that is received. Reducing
and eliminating these disparities therefore requires a multidisciplinary approach.
Using available data, we chose to examine the components of cancer prevention as potential
factors that contribute to disparity. Data from DCR and the BRFS were examined to determine
whether hypotheses could be developed regarding disparities observed in primary, secondary,
and tertiary prevention efforts with disparities observed in cancer incidence and mortality.
The small disparity in colorectal cancer incidence could be related to behavioral risk factors,
including exercise, diet, and obesity. The disparity in colorectal cancer mortality may be due to
lower screening rates. Increased lung and bronchus cancer incidence rates observed among
African Americans run counter to their lower smoking rates. The substantial disparity observed
among African Americans with prostate cancer cannot be explained by either of these factors.
African American men were slightly more likely to have cancer risk factors but were also more
likely to be screened. They were less likely to have advanced disease; however, their prostate
cancer incidence and mortality rates were substantially higher than those of other races. While
female breast cancer screening rates between Whites and African Americans were comparable,
African Americans were more likely to be diagnosed with advanced disease, which may be a
contributing cause of higher breast cancer mortality among African American women.
LIMITATIONS
This investigation had two major limitations. The first was that there were insufficient numbers
of cases to examine cancer incidence and mortality rates and time trends consistently for
racial/ethnic groups other that Whites and African Americans. This was a function of the size of
Delaware and its smaller Hispanic population relative to the national population (five versus 14
percent). The second limitation was the limited amount of data available from DCR. To make
some inferences about the causes of disparity, we would need to examine behavioral cancer risk
factors, screening usage, socioeconomic factors, health literacy, and patient and system barriers
to health care in the population that developed cancer. This limitation is currently being address
by a retrospective study of Delaware residents who were diagnosed with colorectal, female
breast, lung and bronchus, and prostate cancer between 1999 and 2003. Study participants are
interviewed regarding their demographics, access to health care, risk factors for cancer,
screening history, and the cancer treatment received.
1. INTRODUCTION
Cancer is a major public health burden in the United States. In Delaware, as in other States, this
burden is not distributed equally along demographic lines. Variations in cancer incidence and
mortality exist by race/ethnicity, sex, age, and socioeconomic status. While increased attention is
being given to describing cancer-related disparities, the factors that give rise to these disparities,
and how they are interrelated, is poorly understood.
This report presents Delaware cancer rates by race/ethnicity to determine the extent of these
disparities. The rate of difference in the incidence of and mortality from female breast,
colorectal, lung and bronchus, and prostate cancer, and these four major cancers combined
among different racial/ethnic groups in Delaware and how these rates compare with those of the
United States as a whole is described. The effect of sex, age, and county of residence on
disparities in cancer incidence and mortality is also examined, and potential factors that may
explain the variations in incidence and mortality by race/ethnicity are presented. Specifically, we
include a description of population-based modifiable risk factors and screening measures
available. Because stage of disease at diagnosis is a major prognostic factor, one that potentially
contributes to differential mortality rates, this report describes variations in the stage of disease
for the major cancers. Cancer treatments received are examined and compared across racial
groups.
1.1. DELAWARE CANCER STATISTICS
Twenty-five percent of all deaths in Delaware from 1999 to 2002 were caused by cancer (1). The
average annual age-adjusted cancer mortality rate from 1998 to 2002 was 211.6 per 100,000
persons in Delaware, compared with 197.9 among all states (2). The American Cancer Society
(ACS) estimated that in Delaware in 2005, 3,800 cancer cases would be diagnosed and 1,580
deaths would be attributed to cancer (3). The most commonly diagnosed cancers from 1998 to
2002 were lung and bronchus (16 percent), female breast (15 percent), prostate (15 percent), and
colorectal cancer (12 percent). These four cancers are also among the leading causes of cancer
deaths in the State (2).
1.2. DISPARITIES IN CANCER BURDEN
Research conducted across the United States has observed that the burden of cancer varies by
race/ethnicity and socioeconomic status (4–8). According to the most recently released United
States data from 1997 to 2001 for all cancer sites combined, African American men are
20 percent more likely to be diagnosed with cancer than White men, while African American
women are 10 percent less likely to be diagnosed with cancer than White women. African
American men are 60 percent more likely to be diagnosed with prostate cancer, 50 percent more
likely to be diagnosed with lung and bronchus cancer, and 10 percent more likely to be
diagnosed with colorectal cancer than White men. Among women, African American women are
20 percent more likely to be diagnosed with colorectal cancer, equally likely to be diagnosed
with lung and bronchus cancer, and 20 percent less likely to be diagnosed with breast cancer than
White women (9).
There is further evidence of disparity by race/ethnicity in mortality rates. Examining overall data
from the United States, African American men are 40 percent more likely to die of cancer than
White men, and African American women are 20 percent more likely to die of cancer than White
women. The largest disparity is observed in prostate cancer mortality rates, which are 2.4 times
higher for African American men than White men. Increased mortality in African Americans is
also observed for colorectal, female breast, and lung and bronchus cancer: five-year survival
rates are higher for Whites than for African Americans, even after adjusting for differences in the
distribution of tumor stage (9).
1.2.1. Factors That Contribute to Disparities
Differences that exist both within and between racial/ethnic groups can be described by many
factors. A recent report by the Institute of Medicine proposed that health disparities arise as a
result of a complex relationship between social, economic, and cultural factors (10, 11). Potential
explanations attribute these racial/ethnic disparities in cancer incidence and mortality to
dissimilarities in 1) exposure to cancer risk factors, including unhealthy diets and cancer-causing
agents, 2) socioeconomic status, and 3) access to early detection services and quality medical
care (10–12).
To address and ultimately eliminate health disparities, Congress passed the Minority Health and
Health Disparities Research and Education Act of 2000, which created the National Center on
Minority Health and Health Disparities (NCMHD) as a department within the National Institutes
of Health (NIH). In addition, the Center to Reduce Cancer Health Disparities was created within
the National Cancer Institute (NCI) to focus specifically on the issue of health disparities in
cancer. The goal of both these centers is to increase research on health disparities, training for
careers in health disparities, and community intervention and information dissemination to
minimize health disparities. In the NCMHD strategic plan, the model outlined in figure 1 is used
to describe the complex interaction of factors that are thought to create health disparities (13).
The items highlighted in red are aspects that are considered in this report.
Figure 1. A model for the development of health disparities
National data suggest that there is evidence of disparities in behavioral risk factors. The national
Behavioral Risk Factor Surveillance System (BRFSS) data suggest that minorities are less likely
to exercise and more likely to be overweight or obese as compared with Whites (14).
Research has examined the degree to which socioeconomic status affects disparities in cancer
incidence and mortality rates among racial/ethnic groups. Studies that examined cancer diagnosis
and mortality have found that socioeconomic status is a stronger predictor than race/ethnicity (8).
Socioeconomic status, particularly in terms of income and education, is a strong determinant of
working in high-risk occupations and of access to health care; these factors are associated with
both developing and surviving cancer. Disproportionate numbers of racial/ethnic minorities
compared with Whites live at or below the poverty level. African Americans are twice as likely
and Hispanics are four times more likely to have less than a high school education than Whites.
Income generally increases with educational attainment; however, at each level of education,
income is typically higher for Whites and Asians/Pacific Islanders than African Americans and
Hispanics. According to a recent report on the health status of the Nation, men aged 25–64 with
annual incomes of less than $10,000 were 2.4 times more likely to die of lung and bronchus
cancer than those with annual incomes of $25,000 or more (15). Less-educated men and women
had mortality rates two to three times higher than individuals with education levels beyond high
school (16, 17).
Use of screening tests is strongly associated with health insurance and a reliable source of care
(18). National data have shown that, overall, use of screening tests (including female breast
examinations and mammography and colorectal and prostate examinations) among African
Americans is comparable with their use among Whites. However, in the United States 11 percent
of the African American population and almost 23 percent of the Hispanic population report no
health insurance or reliable source of care, compared with fewer than seven percent of Whites
(19).
1.3. OBJECTIVES
An analysis of cancer incidence and mortality was conducted to measure the racial/ethnic
disparities in these outcomes in Delaware. Potential determinants of these disparities were also
analyzed, including aspects of primary (behavioral risk factors), secondary (screening), and
tertiary (treatment) prevention, and previous literature on societal and policy factors was
explored.
Specific objectives of this report include:
* Describing differences in incidence and mortality rates for site-specific cancers and all cancer
sites combined among racial/ethnic groups in Delaware by age, sex (where applicable), and
county of residence
* Examining changes in cancer incidence and mortality in Delaware over time by
race/ethnicity, and sex
* Exploring whether there are disparities in access to health care, modifiable behavioral risk
factors, use of screening tests, stage at diagnosis, and cancer treatments received
The literature on cancer-related community knowledge, beliefs, and behaviors; patient and
provider factors; and service gaps, policy, and societal factors that may contribute to our
understanding of cancer incidence and mortality disparities are briefly summarized.
2. METHODS
The methods section is divided by objective. Within each objective, the data sources are
described, created variables are explained, and the analytic methods are outlined. This structure
was chosen because each data source had a different subset of information available, and the
objective drove the choice of data source and variables.
2.1. INCIDENCE AND MORTALITY DATA
2.1.1. Data Sources
Data used in the analyses derived from both state and federal sources.
2.1.1.1 Delaware Cancer Registry
Delaware cancer incidence data were obtained from the Delaware Cancer Registry (DCR), the
State’s central cancer information center and part of the Health Information and Epidemiology
section of the Delaware Department of Public Health. Delaware is one of 45 States supported by
the National Program of Cancer Registries (NPCR) of the Centers for Disease Control and
Prevention (CDC).
DCR is population-based, collecting data on all cancer patients who are residents of Delaware at
the time of diagnosis. DCR collects information on newly diagnosed cancer cases, cancer
treatments received, and cancer deaths, as well as follow-up data. As stated in the Delaware
Cancer Control Act of 1980, the purpose of the registry is to “ensure an accurate and continuing
source of data concerning cancer and certain specified tumors of a benign nature.” The
confidentiality of patient information in the registry database is a requirement of this law (20).
Quality assurance is performed by a certified tumor registrar to ensure that the registry database
includes complete and accurate data that conform to standards established by the North
American Association of Central Cancer Registries (NAACCR) and NPCR.
DCR’s 1997, 1998, 1999, and 2002 incidence data have been certified by NAACCR as meeting
standards for high-quality data. Table A1 in appendix A lists the criteria for and results of the
NAACCR certification for Delaware’s 2002 incidence data. DCR also submits data annually to
NPCR. DCR’s data submission in 2005 of cases diagnosed from 1998 to 2002 met NPCR’s
standards for quality, completeness, and timeliness.
2.1.1.2 Surveillance, Epidemiology, and End Results Program
The national cancer incidence data used for comparison with the Delaware cancer incidence data
were provided by the NCI Surveillance, Epidemiology, and End Results (SEER) Program. SEER
was established in support of the National Cancer Act of 1971, which mandates the collection,
analysis, and dissemination of data used in the prevention, treatment, and analysis of cancer.
Data from five States, six metropolitan areas, and the Alaska Native registries are used in the
national analyses. These areas include Connecticut, Hawaii, Iowa, New Mexico, Utah, Atlanta,
Detroit, Los Angeles, San Francisco/Oakland, San Jose/Monterey, and Seattle/Puget Sound and
cover approximately 14 percent of the population of the United States. SEER data are currently
the most accurate source of cancer incidence data and therefore were used as a proxy for
disparities observed in the United States. Table 1 compares some of the demographics for
Delaware and the SEER population. Information on SEER characteristics were provided by NCI
(21), and Delaware data were collected from the U.S. Census Bureau (22).
Table 1. Comparison of Delaware with the SEER Population
Race/Ethnicity
Delaware
SEER
Whites
African Americans
American Indians/Alaska Natives
Asians/Pacific Islanders
Hispanics
77
20
0.4
2.2
4.8
67
11
1.4
7.4
19
Live below poverty level
6.5
12
High school graduate
83
78
Live in urban areas
80
89
Foreign born
5.7
15
Delaware differs from the SEER population with regard to the factors examined above; this will
have considered when comparing Delaware statistics with SEER data.
2.1.1.3 National Center for Health Statistics
National mortality data were obtained from the National Center for Health Statistics (NCHS) and
were accessed using SEER*Stat. Cancer deaths from 1980 to 1998 were coded in International
Classification of Diseases, Ninth Revision (ICD-9) format, and deaths that occurred between
1999 and 2002 were coded using the ICD, Tenth Revision (ICD-10).
2.1.1.4 Census Data
Population estimates by race/ethnicity, sex, and age for the United States and for Delaware and
its three counties (Kent, New Castle, and Sussex) were obtained from NCI’s datasets based on
data supplied by the U.S. Census Bureau for 1998–2002 (23). All rates were then age-adjusted to
the U.S. population using the 2000 census standard distribution. Other cancer reports in
Delaware use the Delaware Population Consortium population estimates (24), which may lead to
small differences between results included in this report and other reports.
2.1.2 Variable Definitions
Cancer incidence and mortality statistics are provided for all cancer sites combined and
individually for female breast, colorectal, lung and bronchus, and prostate cancer. For each
cancer site, statistics are provided by race/ethnicity, age, sex, and county of residence.
The category of all cancer sites was defined by:
* Restricting to cases with valid data for age, sex, race/ethnicity, and year of diagnosis
* Restricting to malignant cancers, except for urinary bladder cancer where in situ is included
* Excluding non-melanoma skin cancer
* Excluding prostate cancers with a histology code of 8148
Individual cancers were defined using ICD for Oncology, Third Edition (ICD-O-3) codes for
malignant cancers (25). Colorectal cancer was defined using codes C18.0–18.9, C26.0, and
C20.9; lung and bronchus cancers were defined using codes C34.0–34.9; female breast cancer
was defined using codes C50.0–C50.9, excluding 50.7; and prostate cancer was defined using
code 61.9 (except for cases with an ICD-O-3 histology code of 8148).
These definitions and exclusions are similar to those used by NPCR, and the guidelines can be
found in the NPCR data submission guidelines (26). All criteria, except the exclusion for prostate
cases with a histology code of 8148, were in place during the entire five-year period between
1998 and 2002. The exclusion for prostate cancer came into effect only in 2001, but we excluded
it throughout for consistency. This histologic code was rare and lead to the exclusion of only two
cases.
There was minimal impact from restricting our analyses to individuals with valid demographic
data. Information on individuals missing race/ethnicity information is presented in table A2 in
appendix A.
Race/ethnicity was categorized as White, African American, Hispanic, Asian/Pacific Islander,
and American Indian/Alaska Native. Individuals of any race with a Hispanic ethnicity were
categorized as Hispanic. Age was grouped as follows: 20–39 years, 40–49 years, 50–64 years,
65–79 years, and 80 or older.
2.3 Analytic Methods
2.3.1 Direct Standardization
Five-year average age-adjusted incidence and mortality rates in Delaware and its counties were
computed using data from DCR and NCHS. To measure whether there are disparities in cancer
incidence and mortality among racial and ethnic minorities, incidence and mortality rates were
compiled for all cancer sites combined and four site-specific cancers (female breast, colorectal,
lung and bronchus, and prostate cancer). These cancer sites were chosen because they contribute
56 percent of new cancer cases and 52 percent of cancer deaths and were therefore the most
likely candidates to provide a sufficient sample size to address our research objectives. Incidence
and mortality rates (per 100,000 population) were calculated as the number of new cancer cases
or cancer deaths, respectively, divided by the population counts for subgroups categorized by
race/ethnicity, sex, age, and county of residence. Data were combined to compute five-year
averages because incidence and mortality case counts for any given year are very small for some
subgroups. All rates for State- and county-level analyses were age-standardized by the direct
method to the year 2000 standard U.S. population using SEER*Stat (19). We calculated a
95-percent confidence interval around each rate that was computed.
Cancer incidence and mortality rates were also calculated using the SEER population as a proxy
for national data. Comparisons between Delaware and the SEER data were made by examining
rates and 95-percent confidence intervals. (Rates were determined to be comparable if the
confidence intervals overlapped.)
2.3.2 Disparities in Incidence and Mortality
Disparities in cancer rates were measured by comparing age-, sex-, and county-specific rates for
the different racial/ethnic groups. In order to estimate excess risk, rate ratios and rate differences
were calculated using Whites as the reference category.
The rate ratio was computed by dividing the age-adjusted incidence or mortality rate for any
single minority group by the rate for the reference category. When the rate ratio was equal to
one, there was no disparity in the rates being compared. If the rate ratio was greater than one,
then cancer incidence or mortality was greater in the minority group than among Whites. If the
rate ratio was less than one, then cancer incidence or mortality was greater among Whites than in
the minority group.
A Taylor series expansion was used to generate the 95-percent confidence intervals for rate ratios
comparing minorities with Whites (27), using the software application EpiBasic (28). If the
confidence intervals for the two rate ratios did not overlap, the ratios were said to be significantly
different from one another.
In addition to disparity rate ratios, disparity rate differences were calculated. Using Whites as the
reference group, the rate for Whites was subtracted from the rate for African Americans. Thus,
positive differences indicate that African Americans had a higher incidence or mortality rate,
while negative differences imply greater rates among Whites. The 95-percent confidence
intervals were calculated using EpiBasic.
These two measures are different ways of examining disparity. Rate ratios are used in research to
determine causes of an outcome, in this case, racial disparity in cancer incidence and mortality.
Rate differences present the absolute difference in the rates between, in this case, African
Americans and Whites. Rate differences are more useful for public health research because they
allow investigators to understand the scope of and number of people to be impacted by an
intervention. A rate ratio of two could indicate a change in a rate from two to four or from 200 to
400, which would have different public health implications. The objective of this analysis is to
both understand the causes of racial disparities and inform public health practitioners who will
make recommendations for a cancer control plan to eliminate disparities; therefore, we have
presented both measures.
2.2.3 Trends in Cancer Incidence and Mortality
To examine trends in cancer incidence and mortality from 1980 to 2002, we created graphs with
a data point representing the five-year average rate for every five-year increment between 1980
and 2002. Trends were plotted for all cancer sites combined and individually for female breast,
colorectal, lung and bronchus, and prostate cancer using data from 1980 to 2002. Data are
presented only for Whites and African Americans because other racial and ethnic groups did not
have sufficient sample sizes to be included. Trends were examined for both incidence and
mortality. We separated trends by men and women since the patterns observed differed by sex.
The graphs were examined to determine whether rates were increasing or decreasing over time
and whether the differences between rates in African Americans and Whites were increasing or
decreasing over time.
2.2.4 Data Reporting Rules
In order to maintain the confidentiality of Delaware residents diagnosed with cancer, when
frequency data are presented, cells with five or fewer people are not displayed. In addition, rates
that are based on 25 or fewer people in the numerator are considered unstable and are not
presented.
2.3 BEHAVIORAL CANCER RISK FACTORS AND SCREENING USAGE
2.3.1 Data Sources
The BRFSS was created to survey personal health behaviors and accompanying risk factors that
influence premature morbidity and mortality at the State and national levels among individuals
aged 18 or older. For this analysis, we selected relevant elements from the BRFSS survey in
order to assess potential risk factors and screening measures for identified cancer incidence and
mortality rate discrepancies in Delaware. The results were analyzed to determine what health
behavior and risk factors could be associated with disparities in cancer detection and treatment in
Delaware. Indicators included mammography screening (female breast cancer), tobacco use
(lung and bronchus cancer), and various health risk behavior indicators such as health status,
alcohol use, and obesity (associated with most forms of cancer). The wording of the BRFSS
questions used is included in table C1 of appendix C.
2.3.2 Variable Definitions
For this analysis, BRFSS data collected in 2002 were used to obtain prevalence estimates of
modifiable cancer risk factors, including tobacco use, exercise, diet, obesity, and alcohol
consumption. The data for 2002 were used because they included all the variables of interest and
matched the last year of data from the cancer registry. For each of the five risk factors, we
categorized respondents based on whether they were at risk. Individuals were considered to be at
risk if they 1) were current or former smokers, 2) reported no occupational or leisure-time
physical activity, 3) ate fewer than five servings of fruits and vegetables a day, 4) had a body
mass index (BMI), a ratio between an individual’s height and weight, of 25 or greater, or 5) were
chronic drinkers (women who drank two or more drinks per day or men who drank three or more
drinks per day).
The prevalence of colorectal and prostate cancer screening was estimated among respondents
aged 50 years or older. Colorectal cancer screening was estimated using two different tests: 1) a
home-administered fecal occult blood test kit within the past year or 2) a sigmoidoscopy or
colonoscopy in the past five years. Prostate cancer screening was estimated for men who
reported having had a prostate-specific antigen (PSA) test or digital rectal exam in the past year.
Prevalence estimates of mammography screening during the past two years were reported for
women aged 40 years or older; the prevalence of receiving clinical breast exams in the past two
years was reported for all women. It should be noted that for all the screening tests, the BRFSS
does not distinguish between tests performed for screening purposes and tests performed for
diagnostic purposes.
Race was defined as White, African American, Hispanic, and Other. Other includes Asians,
Pacific Islanders, American Indians, and Alaska Natives. Individuals of any race who have a
Hispanic ethnicity are included in the Hispanic category, not their race category. For behavioral
factors, age was grouped as follows: younger than 40 years, 40–49 years, 50–64 years, 65–79
years, and 80 years or older. Education was categorized as less than high school education, a
high school graduate with no further education, a high school graduate with one to three years of
college, and college graduates. Income referred to the annual household income from all sources
and was categorized as less than $25,000, $25,000–49,999, and $50,000 or more. Health care
access was measured by having any type of health insurance coverage, a doctor that the
individual considered to be his or her personal doctor, and a usual source of care (defined as
seeking non-emergency care in physicians’ offices, clinics, or community health centers and not
at emergency rooms or urgent care centers).
2.3.3 Analytic Methods
Data analyses were conducted using SAS version 9.1 (29). The prevalence of behavioral risk
factors for cancer, access to health care, and use of screening among Delaware residents was
compared with BRFSS data for the entire United States (30). Data were presented only for
groups that had at least 50 people in the denominator. A table with the denominator for all
questions by race/ethnicity is included as table C2 in appendix C. This standard is used by CDC
for the presentation of BRFSS data (14).
Multiracial individuals were excluded from the analysis because of small sample sizes. We were
also unable to examine the prevalence of cancer screening tests among Hispanics. There were
120 Hispanics included in the 2002 sample of the BRFSS; however, most of the screening tests
are sex-specific, which decreased the number by half. Furthermore, 60 percent of the Hispanics
were younger than 40, below the minimum age for screening.
All prevalence estimates were weighted to reflect Delaware’s population distribution.
Multivariate logistic regression models were used to predict each behavioral risk factor or
screening test by the following independent variables: race, age, sex, county of residence,
socioeconomic status, and access to health care. Models were also created to predict each of the
access-to-health-care variables by race, age, sex, county of residence, and socioeconomic status.
Therefore, each model was adjusted for all the independent variables. The logistic regression
procedure accounted for the sampling and weighting used in the BRFSS. The available variables
to measure socioeconomic status were income and education, but we chose to include only
education in the model because data on education were available for 99.9 percent of the
population, while data on income were available for only 71.3 percent. Education and income
have a correlation coefficient of 0.42; this suggests that they are moderately correlated, making
education a reasonable marker for income.
2.4 CANCER STAGE AT DIAGNOSIS
2.4.1 Data Sources
The association between stage at diagnosis and variables related to disparities was examined
using DCR data. Data were aggregated from 1998 to 2002, the five most recent years of
available data. Disparities in the stage at diagnosis for female breast, colorectal, and prostate
cancer were examined because these cancers have recommended screening tests.
2.4.2 Variable Definitions
Stage of cancer was categorized using the SEER summary stage, a scale that categorizes cancers
as in situ, local, regional, distant, or unstaged, using the following definitions:
* In situ—Presence of malignant cells within the cell group from which they arose
* Local—Invasive neoplasm confined entirely to the site of origin
* Regional—Tumors that have extended beyond the limits of the site of origin
* Distant—Tumors that have spread to parts of the body remote from the primary site of origin
* Unstaged—Tumors with insufficient information to assign a stage
SEER summary stage does not account for tumor size or other pathological features, as does the
American Joint Committee on Cancer’s tumor, node, and metastasis classification system;
however, SEER summary stage is the most routinely collected and allows for comparison with
SEER data.
In situ tumors were excluded, but all other stages were examined.
2.4.3 Analytic Methods
Disparities in the stage at diagnosis were examined by race/ethnicity, age, sex, and county of
residence. Race/ethnicity data were categorized as White, African American, Hispanic,
Asian/Pacific Islander, and American Indian/Alaska Native. Hispanics included individuals of all
races. Data on American Indians/Alaska Natives did not meet the requirement of at least 50
individuals in the denominator and therefore were not presented; data on Hispanics and
Asians/Pacific Islanders were presented in crude tables, but the data were too sparse for stratified
analyses. Disparities in stage at diagnosis were examined by age to see whether the disparities
were observed to a lesser or greater extent in those who were younger than 40 for female breast
cancer and younger than 50 for colorectal and prostate cancer because those individuals were too
young for screening to be recommended. Older individuals were also examined to determine
whether Medicare coverage eliminated disparities. All newly diagnosed cancers between 1998
and 2002 that were coded as unstaged were removed from the analysis. In table A3 in appendix
A, the proportion of cases coded as unstaged are presented for each cancer type and compared
with the percentage unstaged in the SEER data. All cancers classified as regional or distant were
combined to form a category that represented cancers diagnosed at advanced stages. Patients
diagnosed with regional and distant cancers usually have a less favorable prognosis than those
diagnosed with local cancer.
2.5 CANCER TREATMENT
Initial attempts to examine disparities in cancer treatment used only the treatment-related data
resident in the DCR; i.e., did not include review of any source records from which the DCR data
derive. The data formats and variable definitions conformed to conventions outlined by the
NAACCR version 10.1 data dictionary (31). The analyses were restricted to cancers diagnosed at
local disease stage because the treatment guidelines are clearer; table A3 in appendix A shows
the proportion of cases that were therefore not included in the treatment analyses. The treatment
analyses were restricted to individuals whose cancer was reported from a facility in Delaware
and whose cancer was diagnosed or treated – or both diagnosed and treated – at that facility.
To compare treatments, we created a variable to represent “standard” treatment in 2001.
Standard treatment was defined using the NCI Physician Data Query as reported in an article by
Shaver et al. (32). This variable was created for female breast, colorectal, lung and bronchus, and
prostate cancer. A description of the definition and codes used to categorize individuals into
treatment groups for each of the cancers examined is included in table A4 of appendix A. The
risk of not receiving standard treatment was examined using multivariate logistic regression;
analyses were performed using SAS version 9.1 (29).
Results of these initial analyses strongly suggested DCR treatment data were not sufficiently
complete/accurate to support this type of analysis without reference to source documents. To
address that limitation, the Delaware Cancer Consortium undertook a validation study to
determine if the treatment-related data in the DCR accurately reflected the treatment received, as
documented in individual facility patient and cancer registry records. The validation study was
limited to breast and colorectal cancer cases, and included all cases (n = 334) designated during
the initial analyses as not having received standard treatment. All reviews were conducted by the
physician oncologist members of the Consortium, and were designed to capture both treatments
received and justifiable reasons for a lack of treatment, e.g., patient refusal or the presence of co-
morbid conditions precluding certain treatments. Both patients whose source documents
reflected receipt of standard treatment and those whose lack of standard treatment was deemed
justifiable were designated as having received “appropriate” treatment. Review results were
incorporated into all subsequent treatment analyses.
2.6 DATA INTERPRETATION
Data in this report are presented as rates, rate ratios, and odds ratios, each with a corresponding
95-percent confidence interval. In addition, percentages and percentage differences are
displayed. There are a number of ways that the data can be interpreted. From a clinical or public
health standpoint, the definition of an important result is a difference that exceeds what is
considered clinically acceptable or what we have the knowledge and resources to address.
Statistically significant results are defined as rate ratios and odds ratios where the confidence
interval does not include one. In situations where there is a comparison of two rates, rate ratios,
or odds ratios, statistically significant results are situations where the confidence intervals do not
overlap. To give readers the ability to identify statistically significant results, two measures are
indicated as being different only if they are statistically significantly different. Results that are
potentially important but not statistically significant are noted; however, in these cases it is stated
that the data suggest there may be an effect.
3. RESULTS
3.1. CANCER INCIDENCE AND MORTALITY
The objective of this section is to determine whether there are racial/ethnic disparities in cancer
incidence and mortality, and in situations where disparities exist to measure the magnitude of the
disparity. The results of the analyses using incidence data from DCR and mortality data from
NCHS from 1998 to 2002 are reported, and the contribution of race/ethnicity, age, sex, and
county of residence to the disparities in cancer incidence and mortality are discussed. The results
are presented for all cancer sites combined and by site for female breast, colorectal, lung and
bronchus, and prostate cancer. The results are first presented for racial/ethnic disparities, and
then, stratifying by race, we present the results for sex, age, and geographic disparities.
3.1.1. Cancer Burden in Delaware
Table 2 presents the number of Delaware residents who were diagnosed with and who died from
cancer between 1998 and 2002 for all cancer sites combined and for each of the four major
cancer sites by race/ethnicity.
Table 2. Number of New Cancers and Deaths from Cancer in Delaware, by
Race/Ethnicity
Incidence
Mortality
White
African
American
Hispanic
Asian
White
African
American
Hispanic
Asian
All sites
16,416
2,867
187
150
7,002
1,249
80
42
Female
breast
2,322
392
23
31
513
115
6
< 6
Colorectal
1,841
324
9
19
676
140
< 6
< 6
Lung and
bronchus
2,609
418
18
13
2,128
335
18
8
Prostate
2,448
591
24
13
328
102
< 6
< 6
Sources: DCR; NCHS, 1998–2002.
3.1.2. Disparities in Cancer Incidence and Mortality
The Delaware and U.S. age-adjusted incidence and mortality rates from 1998 to 2002 for all
cancer sites combined and by site for female breast, colorectal, lung and bronchus, and prostate
cancer are presented in this section.
Figures 2 and 3 show the incidence and mortality rates for all cancer sites combined for Whites,
African Americans, Hispanics, and Asians/Pacific Islanders in Delaware and the United States.
Figures 4 and 5 display the incidence and mortality rates individually for female breast,
colorectal, lung and bronchus, and prostate cancer. For the remainder of the section, we present
data only on Whites and African Americans because the data were too sparse for Hispanics and
Asians/Pacific Islanders. Table 3 presents the incidence and mortality rate ratios comparing
African Americans with Whites for Delaware and the United States. For further detail, the
numbers and age-adjusted incidence and mortality rates with 95-percent confidence intervals by
race are displayed in appendix B. In section 3.1.2., figures displaying incidence rates use a y-axis
ranging from 0/100,000 to 600/100,000, while figures displaying mortality rates range from
0/100,000 to 300/100,000.
Figure 2. Age-adjusted incidence rates for all cancer sites combined, Delaware and the
United States
Sources: DCR; SEER Program, 1998–2002.
* In Delaware, African Americans had a higher cancer incidence than Whites for all cancer
sites combined, and rates for Hispanics and Asians/Pacific Islanders were lower than for
Whites.
* Among Whites, cancer incidence was similar in Delaware and the United States, but the rate
in African Americans was higher in Delaware than in the United States, though not
significantly. Cancer incidence rates in Hispanics and Asians/Pacific Islanders were lower in
Delaware than in the United States.
Figure 3. Age-adjusted mortality rates for all cancer sites combined, Delaware and the
United States
Source: NCHS, 1998–2002.
* Cancer mortality was higher among African Americans than Whites in Delaware, while rates
among Hispanics and Asians/Pacific Islanders were lower than for Whites.
* Mortality rates in Delaware were higher than in the United States for all races/ethnicities
except Asians/Pacific Islanders but only significantly higher among Whites.
Figure 4. Age-adjusted incidence rates for the four major cancer sites, by race, Delaware
and the United States
Sources: DCR; SEER Program, 1998–2002.
* In Delaware, African Americans had a significantly higher incidence than Whites for
colorectal and prostate cancer. Incidence rates for lung and bronchus cancer and for female
breast cancer did not differ significantly between African Americans and Whites in
Delaware.
* No differences were observed between Delaware and the United States for African
Americans; i.e., incidence rates for African American Delawareans are similar to those for
African Americans throughout the United States..
* Compared with the United States, rates of female breast cancer and of prostate cancer were
significantly lower in Delaware among Whites, while rates of lung and bronchus cancer were
significantly higher among Whites.
Figure 5. Age-adjusted mortality rates for the four major cancer sites, by race, Delaware
and the United States
Source: NCHS, 1998–2002.
* Mortality was higher in Delaware among African Americans for all the major cancer sites -
even for female breast cancer, where incidence was lower. The differences were significant
for all sites except lung and bronchus cancer.
* For both Whites and African Americans, mortality rates were higher in Delaware than in the
United States for most of the major cancer sites; mortality rates were lower in Delaware than
in the United States for prostate cancer.
Table 3. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites in Delaware and the United States
Cancer Site
Incidence Rate Ratios
Mortality Rate Ratios
Delaware
United States
Delaware
United States
All sites
1.08 (1.04, 1.13)
1.06 (1.05, 1.07)
1.21 (1.14, 1.29)
1.27 (1.27, 1.28)
Female breast
0.90 (0.81, 1.01)
0.83 (0.81, 0.85)
1.33 (1.09, 1.63)
1.34 (1.32, 1.36)
Colorectal
1.19 (1.06, 1.34)
1.17 (1.14, 1.19)
1.47 (1.22, 1.76)
1.40 (1.38, 1.41)
Lung and
bronchus
1.06 (0.96, 1.18)
1.26 (1.23, 1.28)
1.08 (0.96, 1.21)
1.15 (1.14, 1.16)
Prostate
1.68 (1.53, 1.84)
1.60 (1.56, 1.63)
2.48 (1.98, 3.09)
2.46 (2.43, 2.49)
Sources: DCR; SEER Program; NCHS, 1998–2002.
The incidence rate ratio for Hispanics in Delaware was 0.51 (0.44, 0.59), and for Asians the ratio
was 0.58 (0.49, 0.68). The mortality rate ratio for Hispanics in Delaware was 0.72 (0.58, 0.90),
and for Asians it was 0.50 (0.37, 0.68).
The incidence rate ratios show that:
* Cancer incidence in Delaware among African Americans was 8 percent greater for all sites,
19 percent greater for colorectal cancer, and 68 percent greater for prostate cancer. The data
suggest that incidence among African Americans was lower for female breast cancer and
slightly elevated for lung and bronchus cancer.
* Rates among Hispanics and Asians were lower than for Whites.
* Disparities in lung and bronchus cancer incidence were lower in Delaware than in the United
States; disparities for other cancer sites were comparable.
The mortality rate ratios show that:
* Cancer mortality in Delaware among African Americans was 21 percent higher for all sites,
33 percent higher for female breast cancer, 47 percent higher for colorectal cancer, and
148 percent higher for prostate cancer.
* Cancer mortality was lower among Hispanics and Asians than Whites.
* Disparities in Delaware were comparable to the disparities observed in the United States.
3.1.3. Cancer Disparities by Sex, Age, and County of Residence
Next, the racial disparities in incidence and mortality were examined to determine whether they
differed between males and females, by age at diagnosis, and by whether the individual resided
in New Castle, Kent, or Sussex County at the time of his or her diagnosis. The number of new
cases and deaths and the incidence and mortality rates with 95-percent confidence intervals for
all cancer sites combined and the four major cancer sites separately are included in appendix A.
Incidence and mortality rate ratios and rate differences are presented for sex, age, and county of
residence.
3.1.3.1. Disparities by Sex
In table 4 and in figures 6 and 7, the incidence and mortality rate ratios and rate differences are
presented. Data examining disparities between males and females are presented for all cancer
sites, colorectal cancer, and lung and bronchus cancer. The figures displaying rate differences in
this section use a y-axis that ranges from –15/100,000 to 45/100,000.
Table 4. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by Sex, in Delaware and the
United States
Cancer Site
Incidence Rate Ratios
Mortality Rate Ratios
Delaware
United States
Delaware
United States
All sites
Male
Female
1.19 (1.13, 1.26)
0.98 (0.93, 1.04)
1.22 (1.20, 1.23)
0.93 (0.92, 0.94)
1.30 (1.19, 1.41)
1.17 (1.07, 1.27)
1.40 (1.39, 1.41)
1.18 (1.17, 1.19)
Colorectal
Male
Female
1.12 (0.94, 1.33)
1.27 (1.08, 1.49)
1.16 (1.12, 1.20)
1.21 (1.17, 1.26)
1.37 (1.05, 1.79)
1.58 (1.23, 2.03)
1.40 (1.38, 1.42)
1.43 (1.41, 1.46)
Lung and
bronchus
Male
Female
1.11 (0.97, 1.28)
1.09 (0.93, 1.27)
1.44 (1.40, 1.49)
1.08 (1.04, 1.12)
1.18 (1.02, 1.37)
0.99 (0.83, 1.19)
1.35 (1.33, 1.36)
0.95 (0.94, 0.97)
Sources: DCR; SEER Program; NCHS, 1998–2002.
* In Delaware, the data suggest there was greater disparity in cancer incidence for all sites
combined among men than among women, and greater disparity in colorectal cancer
incidence among women than among men. There was no difference by sex for lung and
bronchus cancer.
* There was greater disparity among men with lung and bronchus cancer in the United States
than in Delaware. For other sites, disparities by sex for cancer incidence were comparable.
* The data suggest that disparity in cancer mortality in Delaware was greater among men for
all cancer sites combined and lung and bronchus cancer and greater among women for
colorectal cancer.
* Disparities in cancer mortality by sex were comparable in Delaware and the United States.
Figure 6. Age-adjusted incidence rate differences comparing African Americans with
Whites for colorectal and lung and bronchus cancer, by sex, Delaware and the
United States
Sources: DCR; SEER Program, 1998–2002.
* Among women in Delaware there were significant disparities between African Americans
and Whites for colorectal cancer. There was no evidence of a difference in disparities
between men and women in Delaware and in the United States.
* A difference in disparities in lung and bronchus cancer incidence were observed in the
United States, where men had a higher incidence than women, but not in Delaware.
Figure 7. Age-adjusted mortality rate differences comparing African Americans with
Whites for colorectal and lung and bronchus cancer, by sex, Delaware and the
United States
Source: NCHS, 1998–2002.
* The data suggest that African American women with colorectal cancer were more likely to
die than White women, and African American men were more likely to die of lung and
bronchus cancer than White men. There was no difference between men and women for lung
and bronchus cancer, but the data suggest that disparities were greater among men with lung
and bronchus cancer.
* Disparities in the United States were comparable to disparities in Delaware, but the data
suggest greater disparity for lung and bronchus cancer among men in the United States than
among men in Delaware.
3.1.3.2. Disparities by Age
In table 5 and in figures 8 and 9, the incidence and mortality rate ratios and differences are
presented by age at diagnosis. We examined age at diagnosis using age groupings that
considered ages for screening recommendations (40+ for female breast cancer and 50+ for
colorectal and prostate cancer) and Medicare eligibility (65+), since these factors could be
related to access to screening and health care, which may be a cause of cancer disparities. Data
are presented for all cancer sites combined and for the four major cancer sites individually.
Figures that display the rate differences use graphs with a y-axis that ranges from –400/100,000
to 800/100,000.
Table 5. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by Age, in Delaware
Age (Years)
Incidence Rate Ratios
Mortality Rate Ratios
All sites
20–39
40–49
50–64
65–79
80+
0.86 (0.75, 1.00)
1.17 (1.04, 1.31)
1.15 (1.08, 1.24)
1.01 (0.95, 1.08)
1.06 (0.94, 1.20)
0.99 (0.71, 1.38)
1.53 (1.23, 1.90)
1.25 (1.11, 1.40)
1.18 (1.07, 1.29)
1.12 (0.98, 1.29)
Female breast
20–39
40–49
50–64
65–79
80+
1.36 (0.96, 1.92)
1.24 (1.00, 1.53)
0.81 (0.67, 0.98)
0.70 (0.55, 0.88)
0.94 (0.65, 1.35)
NA
2.41 (1.46, 3.98)
1.78 (1.24, 2.53)
1.06 (0.72, 1.57)
NA
Colorectal
20–39
40–49
50–64
65–79
80+
NA
1.43 (0.96, 2.12)
1.18 (0.94, 1.49)
1.06 (0.88, 1.28)
1.27 (0.98, 1.65)
NA
NA
1.63 (1.13, 2.35)
1.38 (1.05, 1.82)
1.35 (0.93, 1.96)
Lung and bronchus
20–39
40–49
50–64
65–79
80+
NA
1.49 (1.04, 2.14)
1.20 (1.01, 1.42)
0.94 (0.80, 1.10)
0.97 (0.70, 1.35)
NA
1.52 (0.96, 2.40)
1.15 (0.94, 1.41)
1.01 (0.85, 1.19)
1.00 (0.73, 1.36)
Prostate
20–39
40–49
50–64
65–79
80+
NA
NA
1.94 (1.69, 2.23)
1.50 (1.31, 1.72)
1.42 (1.02. 1.97)
NA
NA
NA
3.02 (2.22, 4.11)
2.15 (1.50, 3.09)
NA = Rates based on counts too small to be displayed.
Sources: DCR; NCHS, 1998–2002.
* For both incidence and mortality there was no statistically significant evidence that disparity
differed by age at diagnosis or death.
* However, the data suggest some patterns with respect to age:
* While sufficient data at young ages were not always available, the available data showed
that the disparities were greater at younger ages.
* Disparities among individuals aged 65 or older were usually less than among younger
individuals.
Figure 8. Incidence rate differences comparing African Americans with Whites for the
four major cancers, by age, in Delaware
Source: DCR, 1998–2002.
* There was no evidence of significant differences in cancer disparity by age on the absolute
scale.
Figure 9. Mortality rate differences comparing African Americans with Whites for the
four major cancers, by age, in Delaware
Source: NCHS, 1998–2002.
* The data for colorectal and prostate cancer suggest that disparities in cancer mortality
increased with age. Minimal disparity was observed for lung and bronchus cancer.
3.1.3.3. Disparities by County of Residence
In table 6 and in figures 10 and 11, the incidence and mortality rate ratios and differences are
presented by county of residence at diagnosis. We examined county of residence for all cancer
sites combined and for the four major cancers by site. Figures that display the rate differences
use graphs with a y-axis that ranges from –100/100,000 to 200/100,000.
Table 6. Incidence and Mortality Rate Ratios (With 95-Percent Confidence Intervals)
Comparing African Americans With Whites, by County of Residence, in
Delaware
Cancer Site
Incidence Rate Ratios
Mortality Rate Ratios
All sites
Kent
New Castle
Sussex
0.99 (0.90, 1.10)
1.11 (1.06, 1.17)
1.04 (0.95, 1.15)
1.14 (0.99, 1.32)
1.21 (1.12, 1.30)
1.24 (1.08, 1.42)
Female breast
Kent
New Castle
Sussex
0.79 (0.59, 1.05)
0.96 (0.85, 1.09)
0.80 (0.60, 1.06)
NA
1.31 (1.02, 1.68)
1.84 (1.20, 2.83)
Colorectal
Kent
New Castle
Sussex
1.30 (1.00, 1.69)
1.22 (1.01, 1.40)
0.94 (0.69, 1.27)
1.86 (1.20, 2.90)
1.40 (1.11, 1.77)
1.51 (1.01, 2.24)
Lung and bronchus
Kent
New Castle
Sussex
0.78 (0.59, 1.02)
1.17 (1.03, 1.33)
1.01 (0.80, 1.28)
0.77 (0.58, 1.03)
1.15 (1.00, 1.33)
1.12 (0.87, 1.45)
Prostate
Kent
New Castle
Sussex
1.67 (1.32, 2.11)
1.63 (1.46, 1.82)
1.71 (1.37, 2.14)
NA
1.94 (1.42, 2.66)
NA
NA = Rates based on counts too small to be displayed.
Sources: DCR; NCHS, 1998–2002.
* For all sites combined and for the specific sites of interest, there was minimal difference in
disparities in cancer incidence and mortality by county of residence.
* For mortality, data were sometimes too sparse to present for all counties. However, the data
suggest that colorectal cancer mortality was higher in Kent and Sussex Counties than in New
Castle County, and that lung and bronchus cancer mortality was lowest in Kent County.
Figure 10. Incidence rate differences comparing African Americans with Whites for the
four major cancers, by county of residence, in Delaware
Source: DCR, 1998–2002.
* This figure also presents the differences in cancer incidence among African Americans
compared with incidence among Whites, by county.
Figure 11. Mortality rate differences comparing African Americans with Whites for the
four major cancers, by county of residence, in Delaware
Source: NCHS, 1998–2002.
* The pattern for disparities in cancer mortality by county differed depending on the cancer
site, but no significant interaction by county of residence was observed.
3.2. TRENDS IN CANCER INCIDENCE AND MORTALITY
In this section, Delaware incidence and mortality rates from 1980 to 2002 are presented for all
cancer sites combined and for the four major cancer sites. The analysis was restricted to African
Americans and Whites because we did not have sufficient data for the other races. Results for all
cancer sites combined, colorectal cancer, and lung and bronchus cancer are presented by sex,
since this was an important determinant of the trend. Figures 12–16 include the trends for
incidence, and figures 17–21 display the trends for mortality. Since the annual number for some
cancers and subgroups of interest were small, the five-year average incidence and mortality rates
were plotted for each five-year increment from 1980–1984 through 1998–2002. Trends were
examined to determine whether advances in cancer prevention behaviors, screening, and
treatment have had a similar impact on African Americans and Whites. We examined these
trends to determine whether the rates were increasing or decreasing over time and whether the
difference in rates between African Americans and Whites was increasing or decreasing. No
statistics are presented for the trend analysis; statements about the data reflect visual inspection.
3.2.1. Cancer Incidence in Delaware, 1980–2002
3.2.1.1. All Cancer Sites Combined
Figure 12. Trends in cancer incidence for all sites combined comparing Whites with
African Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: DCR, 1980–2002.
* Cancer incidence rates among White men were consistently lower than those of African
American men and started to decline earlier: the incidence rate for White men peaked
between 1991 and 1995 at 640/100,000, and the rate for African American men peaked
between 1992 and 1996 at 878/100,000.
* The five-year average rate for African American men began declining sharply in 1993–1997.
* Little difference existed between White and African American women, whose incidence rates
were lower than for men and remained stable over time.
3.2.1.2. Female Breast Cancer
Figure 13. Trends in female breast cancer incidence comparing Whites with African
Americans, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: DCR, 1980–2002.
* Breast cancer incidence was consistently higher in White women than African American
women.
* There were sharp increases in incidence seen in all women in 1983-1987 and 1987-1991. In
recent years, incidence decreased for both White and African American women.
3.2.1.3. Colorectal Cancer
Figure 14. Trends in colorectal cancer incidence comparing Whites with African
Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: DCR, 1980–2002.
* Among men, colorectal cancer incidence rates for African Americans were initially lower
than for Whites, but due to a steady upward trend, the rates for African Americans surpassed
the rates for White men in 1988-1992 but then began to decline, while the rates for White
men declined steadily throughout the entire time period.
* A similar pattern was seen for women. African Americans began with lower rates, then their
incidence increased, peaked in 1985-1989, and then declined. However, beginning in 1993-
1997 their incidence rates have been increasing.
* The net result is that disparities in the colorectal cancer incidence rate are widening for
women and possibly for men.
3.2.1.4. Lung and Bronchus Cancer
Figure 15. Trends in lung and bronchus cancer incidence comparing Whites with African
Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: DCR, 1980–2002.
* Rates among African American men were higher than among White men. Incidence for
African American men peaked in 1989-1993 and has been declining steadily since; it is now
approaching the rate observed in White men.
* Lung and bronchus cancer incidence is lower among women than men; however, rates were
increasing until the mid-1990s, but are now decreasing. Rates among African American
women were higher than among Whites, but in recent years their incidence has been similar.
3.2.1.5. Prostate Cancer
Figure 16. Trends in prostate cancer incidence comparing Whites with African Americans,
in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: DCR, 1980–2002.
* During the 1980s, prostate cancer incidence rates were low and climbed slowly for Whites;
for African Americans there was a decline.
* During the early 1990s, rates increased sharply in both races but to a greater extent among
African Americans.
* Rates began to decline in the mid-1990s, but recent data suggest that rates have reached a
plateau and are possibly beginning to increase.
3.2.2. Cancer Mortality in Delaware, 1980–2002
3.2.2.1. All Cancer Sites Combined
Figure 17. Trends in cancer mortality for all sites combined comparing Whites with
African Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: NCHS, 1980–2002.
* Cancer mortality was higher among men than women, and for both sexes mortality was
greater for African Americans than for Whites.
* Mortality rates for African American men peaked in 1989–1993 and have been declining
steadily since.
* For White men and all women, rates declined slightly over time. In White women less than a
10/100,000 difference in mortality was seen over the 20 years examined.
3.2.2.2. Female Breast Cancer
Figure 18. Trends in female breast cancer mortality comparing Whites with African
Americans, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: NCHS, 1980–2002.
* After 1988-1992, breast cancer mortality consistently decreased among White women.
* Mortality for African American women increased until 1986–1990 then decreased to the
extent that in 1991–1995 the rate was comparable to that of White women. However, since
then the mortality rate of African American women has been higher than that of White
women.
3.2.2.3. Colorectal Cancer
Figure 19. Trends in colorectal cancer mortality comparing Whites with African
Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: NCHS, 1980–2002.
* Colorectal cancer mortality steadily declined among White men and women.
* Except during 1989-1994, rates among African American men decreased until 1994–1998
and are now increasing.
* Rates among African American women increased and decreased over time, but there was
little net change.
3.2.2.4. Lung and Bronchus Cancer
Figure 20. Trends in lung and bronchus cancer mortality comparing Whites with African
Americans, by sex, in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: NCHS, 1980–2002.
* After 1989-1994, there was a steady decline in the lung and bronchus cancer mortality rate
among African American men; it is now approaching the mortality rate of White men.
* The rate for African American women was slightly but consistently higher than for White
women until the mid-90’s. The mortality rate of African American women is now similar to
the mortality rate of White women.
3.2.2.5. Prostate Cancer
Figure 21. Trends in prostate cancer mortality comparing Whites with African Americans,
in Delaware
Note: A data point is included for each of the 20 five-year increments, but due to space limitations
only every third point is labeled on the x-axis.
Source: NCHS, 1980–2002.
* The prostate cancer mortality rate has been much higher among African American men than
White men.
* Although there has been a steady decline in the prostate cancer mortality rate among White
men, the rate for African American men did not decline until after 1992-1996, when it
peaked at 105.6/100,000.
* With the mortality rate for African American men declining faster than for White men, the
disparity in rate has also been decreasing.
3.3. FACTORS THAT CONTRIBUTE TO DISPARITIES
This section addresses factors that may contribute to the disparities in cancer incidence and
mortality observed in Delaware. Four areas that are known to influence cancer prevention and
control were examined: 1) risk factors, 2) screening, 3) stage at diagnosis, and 4) treatment.
The following questions were addressed:
* Are there differences in the prevalence of modifiable behavioral risk factors for cancer by
race/ethnicity? Are these differences affected by age, sex, county of residence,
socioeconomic status, and access to health care?
* Does the use of screening tests differ among racial groups in Delaware? Does the use of
screening among racial groups vary by age, sex, county of diagnosis, socioeconomic status,
and access to health care?
* Does the distribution of advanced-stage disease differ by race, age, sex, and county of
diagnosis?
* Does the proportion of cancer patients with local-stage disease who did not receive the
standard treatment differ by race, age, sex, county of diagnosis, and insurance status?
3.3.1. Cancer Risk Factors and Screening Usage
BRFSS data were used to examine behavioral cancer risk factors and cancer screening usage in
Delaware and to compare Delaware with the United States. Table 7 compares demographic
characteristics of the population of Delaware with the United States.
Table 7. Comparison of Demographic Characteristics Between Delaware and the United
States, 2002
Delaware (%)
United States (%)
Total
White
African
American
Hispanic
Total
White
African
American
Hispanic
Race/ethnicity
78
13
5
70
10
14
Age
20–39
40–49
50–64
65–79
80+
40
21
21
14
3
37
21
22
16
4
51
21
17
9
2
9
23
15
2
1
42
20
21
13
4
37
21
23
15
4
47
21
19
10
3
8
19
15
7
1
Sex
Male
Female
48
52
47
53
43
57
57
43
48
52
48
52
44
56
49
51
Education
< High school
High school graduate
Some college
College graduate
9
33
26
32
7
34
26
34
14
37
29
20
36
29
17
18
13
31
27
29
8
31
28
32
16
35
29
20
34
29
23
15
Income
< $25,000
$25,000–$49,000
$50,000+
21
30
49
17
29
53
32
39
29
45
26
29
29
32
38
23
33
44
43
34
23
53
29
18
Source: BRFSS, 2002.
Compared with the United States:
* Delaware had a comparable age and sex distribution.
* Delaware had a larger African American population and a smaller Hispanic population.
* A lower proportion of the Delaware population had less than a high school education.
* A higher proportion of the Delaware population had incomes of greater than $50,000.
Tables 8–10 display differences by race/ethnicity in the prevalence of access to health care,
behavioral risk factors for cancer, and screening usage. A table displaying the denominator for
each variable examined by race/ethnicity is included in table C2 in appendix C.
Table 8. Access to Health Care in Delaware and the United States, by Race/Ethnicity
No Health
Insurance
No Personal Doctor
No Usual Source
of Care
% (95% CI)
% (95% CI)
% (95% CI)
Delaware
White
African American
Hispanic
7.6 (6.2, 9.0)
12.8 (8.7, 16.9)
21.3 (9.0, 33.7)
10.1 (8.0, 12.1)
16.1 (11.1, 21.2)
28.7 (15.5, 41.9)
5.7 (4.6, 6.8)
12.4 (8.2, 16.6)
14.1 (6.4, 21.9)
United States
White
African American
Hispanic
11.1 (10.9, 11.4)
20.3 (19.3, 21.2)
32.3 (31.0, 33.7)
16.8 (16.5, 17.1)
22.5 (21.4, 23.6)
38.2 (36.8, 39.7)
14.9 (14.6, 15.2)
24.8 (23.7, 25.9)
24.6 (23.3, 25.9)
Source: BRFSS, 2002.
* Delaware residents of any race/ethnicity were more likely to have access to health care
compared with residents of the United States. However, due to small numbers, the
differences for Hispanics were not always statistically significant.
* In Delaware, Hispanics were less likely to have health insurance, a personal doctor, and a
usual source of care than Whites; in most instances, the differences were statistically
significant.
* The data suggest that in Delaware, African Americans were also less likely to have health
insurance, a personal doctor, and a usual source of care than Whites; the only statistically
significant difference was in having a usual source of care.
Figure 22 compares the percentage difference in health care access for minorities versus Whites
in Delaware and in the United States. Using the data from table 8, we examined the difference
between the percentage observed in Whites and in non-Whites. Larger differences indicate a
larger disparity between Whites and non-Whites.
Figure 22. Racial/ethnic disparities in access to health care in Delaware and the United
States
Source: BRFSS, 2002.
* For all three measures of access to health care, disparities were observed for African
Americans and Hispanics, compared with Whites.
* The data suggest that the disparities in access to health care were greater for Hispanics
than African Americans.
* There were no significant differences in the magnitude of the disparity when comparing
Delaware with the United States, but the data suggest that in general the disparity was less in
Delaware.
Table 9. Comparison of Modifiable Risk Factors for Cancer Between Delaware and the United
States, by Race/Ethnicity
No Exercise
Former
Smokers
Current
Smokers
Overweight
(BMI: 25–29)
Obese
(BMI: 30+)
Poor Diet
(Fewer Than
Five Fruits and
Vegetables/Day)
Chronic
Alcohol
Intake1
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
Delaware
White
African
American
Hispanic
17.6 (15.9, 19.4)
37.5 (31.3, 43.6)
21.1 (11.7, 30.5)
28.0 (25.9, 30.2)
17.3 (12.8, 21.8)
31.6 (17.4, 45.8)
25.6 (23.1, 28.1)
25.6 (19.7, 31.4)
18.1 (7.0, 29.1)
35.5 (33.0, 37.9)
41.0 (34.7, 47.5)
40.4 (25.8, 55.0)
20.8 (18.7, 22.8)
33.2 (27.3, 39.2)
18.4 (5.5, 31.3)
79.9 (78.0, 81.7)
87.3 (83.7, 91.1)
79.1 (67.6, 90.6)
8.6 (7.0, 10.2)
5.6 (2.4, 8.9)
9.2 (-1.1, 19.5)
United States
White
African
American
Hispanic
20.3 (20.0, 20.6)
30.6 (29.4, 31.7)
35.9 (34.5, 37.2)
27.1 (26.8, 27.4)
16.4 (15.6, 17.4)
18.1 (17.0, 19.2)
23.4 (23.0, 23.7)
21.8 (20.8, 22.8)
18.6 (17.4, 19.7)
36.8 (36.4, 37.2)
36.1 (34.9, 37.3)
39.4 (38.0, 40.9)
20.5 (20.2, 20.8)
33.2 (32.1, 34.4)
24.0 (22.7, 25.3)
75.7 (75.3, 80.0)
77.0 (76.0, 78.1)
77.0 (75.8, 78.2)
6.3 (6.1, 6.5)
3.7 (3.2, 4.2)
4.3 (3.7, 4.9)
1 Women who drank two or more drinks per day or men who drank three or more drinks per day.
Source: BRFSS, 2002.
* African Americans were more likely to have no exercise, be obese, and eat fewer than five fruits
and vegetables per day than Whites.
* The prevalence of behavioral risk factors was comparable in Whites and Hispanics.
* African Americans in Delaware were more likely to have a poor diet than African Americans in the
United States overall. No other differences were statistically significant, but the prevalence of risk
factors seemed to be slightly higher in Delaware.
Figure 23 compares the racial/ethnic disparities in cancer risk factors in Delaware with the
disparities observed in the rest of the United States. As in figure 22, we examined the difference
between the percentage observed in Whites and the percentage observed in non-Whites. Larger
differences indicate a greater disparity between Whites and non-Whites. Negative numbers
indicate that Whites are more likely to engage in a risk factor than African Americans or
Hispanics. We examined the proportion of study respondents who never exercised, were ever
smokers, had a BMI greater than 25, ate fewer than five fruits and vegetables per day, and were
chronic alcohol drinkers.
Figure 23. Racial/ethnic disparities in behavioral cancer risk factors in Delaware and the
United States
Source: BRFSS, 2002.
* The largest disparities for African Americans were in exercise, smoking and obesity. In the
case of smoking, African Americans were less likely to have ever smoked than were Whites.
* The disparity in exercise and diet was greater in Delaware than in the United States.
* Numbers were small for Hispanics, but the data suggest that they had less disparity than
African Americans and that the disparity was less in Delaware than the United States.
Table 10 shows the differences in screening behavior for colorectal, prostate, and female breast
cancer by race. The results show the prevalence of being screened for cancer within the time
interval currently recommended by ACS.
Table 10. Comparison of the Percentage of Individuals Who Have Not Received Cancer-Screening
Tests Within the Recommended Time Interval Between Delaware and the United States,
by Race
% Not Receiving
Test
Fecal Occult
Blood Test
Sigmoidoscopy
or Colonoscopy
Prostate-Specific
Antigen Test
Digital Rectal
Exam
Mammogram
(Females)
Clinical Breast
Exam (Females)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
Delaware
White
African
American
76.2 (73.5, 78.9)
81.3 (73.0, 89.6)
48.6 (45.4, 51.9)
53.1 (42.5, 63.8)
36.6 (31.5, 41.8)
30.8 (15.4, 46.2)
53.1 (48.7, 57.6)
45.8 (31.5, 60.0)
16.0 (13.5, 18.5)
12.8 (5.9, 19.8)
14.6 (12.3, 16.8)
14.3 (8.4, 20.1)
United States
White
African
American
77.5 (77.0, 77.9)
79.6 (77.8, 81.3)
58.7 (58.1, 59.2)
60.4 (58.3, 62.5)
43.6 (42.7, 44.5)
46.5 (43.0, 50.0)
54.5 (53.7, 55.1)
55.9 (53.2, 58.6)
22.8 (22.3, 23.2)
21.9 (20.2, 23.6)
18.2 (17.8, 18.6)
19.7 (18.4, 21.0)
Source: BRFSS, 2002.
* In both Delaware and the United States, there were no significant differences in the proportion
not receiving screening when comparing Whites with African Americans.
* Although the difference is not statistically significant, more African Americans than Whites
in Delaware received screening for prostate cancer and for female breast cancer.
* The data suggest that Delaware residents were more likely to have received screening than did
residents of the United States as a whole.
Figure 24. Racial disparities in cancer screening test usage in Delaware and the United
States
Source: BRFSS, 2002.
* No significant differences in disparity were observed between Delaware and the United
States.
Tables 11, 13, and 15 present the odds ratios and 95-percent confidence intervals from logistic
regression models examining the association between race/ethnicity and the markers of access to
health care, behavioral risk factors, and screening usage, respectively. Tables 12, 14, and 16
present the odds ratios and 95-percent confidence intervals from multivariate models examining
the association between race/ethnicity and the measures above but also include in the model
other, potentially related variables..
Odds ratios greater than one indicate that the subgroup was more likely not to have (or to have,
as applicable) the measure than the reference group; odds ratios less than one indicate that the
subgroup was more likely to have (or not to have) the measure.
Table 11. Association Between Race/Ethnicity and Access to Health Care in Delaware
Odds Ratio (95%
Confidence Interval)
No Health
Insurance
No Personal
Doctor
No Usual Source of
Care
Race/ethnicity
White
African American
Hispanic
Reference
2.0 (1.5, 2.7)
3.1 (1.9, 5.1)
Reference
1.4 (1.0, 1.8)
4.0 (2.6, 6.0)
Reference
1.9 (1.4, 2.5)
3.5 (2.1, 5.8)
Source: BRFSS, 2002.
* This table indicates that compared with Whites, African Americans and Hispanics are more
likely to lack health insurance, a personal doctor, and a usual source of care.
Table 12. Multivariate Regression Model of Predictors of Lack of Access to Health Care
No Health
Insurance
No Personal
Doctor
No Usual Source of
Care
Race/ethnicity
White
African American
Hispanic
Reference
1.5 (1.1, 2.0)
1.6 (0.93, 2.8)
Reference
1.0 (0.76, 1.4)
2.3 (1.4, 3.7)
Reference
1.6 (1.2, 2.3)
2.7 (1.5, 4.7)
Age
< 40
40–49
50–64
65–79
80+
Reference
0.56 (0.41, 0.78)
0.51 (0.37, 0.70)
0.70 (0.04, 1.4)
0.20 (0.09, 0.44)
Reference
0.45 (0.33, 0.60)
0.38 (0.28, 0.51)
0.24 (0.16, 0.36)
0.23 (0.11, 0.47)
Reference
0.59 (0.41, 0.84)
0.52 (0.36, 0.73)
0.51 (0.35, 0.75)
0.58 (0.31, 1.1)
Sex
Male
Female
Reference
0.71 (0.55, 0.90)
Reference
0.54 (0.44, 0.67)
Reference
0.47 (0.36, 0.60)
Education
< High school
High school
graduate
Some college
College graduate
7.8 (5.1, 12.0)
2.7 (1.9, 3.9)
1.8 (1.2, 2.7)
Reference
2.5 (1.7, 3.6)
1.3 (0.95, 1.7)
1.2 (0.87, 1.6)
Reference
2.1 (1.4, 3.1)
1.0 (0.75, 1.5)
1.2 (0.85, 1.7)
Reference
County
New Castle
Kent
Sussex
Reference
1.2 (0.88, 1.7)
1.7 (1.3, 2.3)
Reference
1.2 (1.0, 1.7)
0.97 (0.73, 1.3)
Reference
2.0 (1.4, 2.7)
1.3 (0.90, 1.8)
Source: BRFSS, 2002.
* In each column of table 12, the association between race/ethnicity and each marker of access
to health care is examined after adjustment for age, sex, education, and county of residence.
Therefore in the column for no health insurance, the results are interpreted as African
Americans being 1.5 times more likely than Whites to lack health insurance.
* The odds ratios measuring the effect of race were lower after adjusting for other predictors
of access to health care, suggesting that some of the disparity observed in table 11 can be
explained by the fact that minorities are more likely to have other factors that predict barriers
to access to health care. However, since the race/ethnicity effect was not eliminated after
adjustment for other variables, this indicates that the other variables in the model cannot
account for all of the disparity observed.
* The strongest predictor of not having each of the measures of access to health care was
having less than a high school education.
In tables 13 and 14, separate models were developed to examine this relationship with the
following measures: 1) physical inactivity, 2) current smoking, 3) chronic drinking, 4) BMI
greater than 25, and 5) eating fewer than five fruits and vegetables per day.
Table 13. Association Between Race/Ethnicity and Modifiable Risk Factors for Cancer in Delaware
Race/Ethnicity
No Exercise
Ever Smoked
Obese (BMI: 25+)
Poor Diet
(Fewer Than
Five Fruits and
Vegetables/Day)
Chronic Alcohol
Intake1
White
African American
Hispanic
Reference
2.2 (1.8, 2.7)
1.4 (0.94, 2.1)
Reference
0.56 (0.46, 0.68)
0.65 (0.45, 0.94)
Reference
2.2 (1.7, 2.7)
0.98 (0.67, 1.4)
Reference
1.6 (1.2, 2.0)
0.90 (0.58, 1.4)
Reference
0.64 (0.40, 1.0)
0.82 (0.35, 1.9)
1 Women who drank two or more drinks per day or men who drank three or more drinks per day.
Source: BRFSS, 2002.
* African Americans were more likely to report having no exercise, being obese, and eating
fewer than five fruits and vegetables per day, and they were less likely to have ever smoked.
* There were no significant differences observed between Hispanics and Whites.
Table 14. Multivariate Regression Model of Predictors of Having Modifiable Risk Factors for
Cancer in Delaware
No Exercise
Ever Smoked
Obese (BMI: 25+)
Poor Diet
(Fewer Than Five
Fruits and
Vegetables/Day)
Chronic Alcohol
Intake1
Race/ethnicity
White
African American
Hispanic
Reference
2.4 (1.9, 3.0)
1.8 (1.1, 3.0)
Reference
0.55 (0.45, 0.67)
0.70 (0.46, 1.1)
Reference
2.5 (2.0, 3.2)
1.2 (0.75, 1.9)
Reference
1.4 (1.1, 1.8)
0.71 (0.43, 1.2)
Reference
0.54 (0.33, 0.88)
0.25 (0.06, 1.0)
Age
< 40
40–49
50–64
65–79
80+
Reference
1.3 (0.98, 1.6)
1.7 (1.3, 2.1)
2.4 (1.9, 3.1)
3.4 (2.4, 4.8)
Reference
1.3 (1.1, 1.6)
1.9 (1.6, 2.2)
1.8 (1.5, 2.2)
0.82 (0.59, 1.1)
Reference
1.4 (1.2, 1.7)
2.0 (1.6, 2.4)
1.7 (1.4, 2.1)
0.80 (0.58, 1.1)
Reference
0.96 (0.77, 1.2)
0.92 (0.73, 1.2)
0.62 (0.49, 0.79)
0.57 (0.40, 0.82)
Reference
0.88 (0.62, 1.3)
0.56 (0.38, 0.83)
0.52 (0.33, 0.81)
0.26 (0.09, 0.73)
Sex
Male
Female
Reference
1.8 (1.5, 2.2)
Reference
0.65 (0.57, 0.74)
Reference
0.47 (0.41, 0.54)
Reference
0.48 (0.40, 0.57)
Reference
0.66 (0.50, 0.87)
Education
< High school
High school graduate
Some college
College graduate
4.4 (3.3, 5.9)
2.2 (1.8, 2.7)
1.6 (1.2, 2.0)
Reference
2.2 (1.7, 2.8)
1.7 (1.4, 2.0)
1.5 (1.3, 1.8)
Reference
1.9 (1.5, 2.6)
1.6 (1.3, 1.9)
1.4 (1.2, 1.7)
Reference
2.3 (1.6, 3.2)
1.9 (1.6, 2.3)
1.6 (1.3, 1.9)
Reference
1.1 (0.58, 2.0)
1.3 (0.89, 1.9)
1.4 (0.99, 2.1)
Reference
County
New Castle
Kent
Sussex
Reference
1.1 (0.88, 1.3)
0.95 (0.78, 1.2)
Reference
1.0 (0.87, 1.2)
1.0 (0.85, 1.2)
Reference
1.2 (1.0, 1.5)
1.2 (1.0, 1.4)
Reference
1.1 (0.90, 1.3)
1.1 (0.90, 1.3)
Reference
0.48 (0.34, 0.70)
0.74 (0.54, 1.0)
Health insurance
Yes
No
Reference
1.2 (0.85, 1.6)
Reference
1.4 (1.1, 1.9)
Reference
0.78 (0.58, 1.0)
Reference
0.95 (0.68, 1.3)
Reference
1.5 (0.95, 2.5)
Personal doctor
Yes
No
Reference
1.1 (0.80, 1.5)
Reference
0.99 (0.76, 1.3)
Reference
0.74 (0.56, 0.98)
Reference
1.0 (0.76, 1.5)
Reference
1.2 (0.73, 1.9)
Usual source of care
Yes
No
Reference
0.81 (0.57, 1.1)
Reference
1.3 (0.96, 1.7)
Reference
0.94 (0.71, 1.3)
Reference
1.1 (0.80, 1.6)
Reference
1.6 (0.98, 2.7)
1 Women who drank two or more drinks per day or men who drank three or more drinks per day.
Source: BRFSS, 2002.
* After adjusting for demographic characteristics and access to health care variables, the
odds ratios for the associations between race/ethnicity and exercise and obesity were greater than
the crude (i.e., unadjusted) odds ratios. This suggests that after including other potential
predictors in the model, the effect between being African American and the risk of not
exercising or being obese was stronger.
* Having less than a high school education was a consistent strong predictor of being at risk
for each of the five factors examined. Access to health care was not a predictor of being at risk
for any factors, except not having health insurance increased the risk of ever smoking.
Multivariate logistic regression models were developed to analyze whether the disparities in the
use of cancer screening tests were due to race/ethnicity or were confounded by other factors,
including socioeconomic status and access to health care. Separate models were developed for
each screening test, and the outcome was the proportion of study respondents who did not
receive the screening test within the recommended interval. The recommended time intervals for
these analyses were:
* A fecal occult blood test in the past year among individuals aged 50 or older
* A sigmoidoscopy/colonoscopy in the past five years among individuals aged 50 or older
* A prostate-specific antigen test in the past year for men aged 50 or older
* A digital rectal exam in the past year for men aged 40 or older
* A mammogram every two years for women aged 40 or older
* A clinical breast exam in the past two years for women
Odds ratios greater than one indicated that the subgroup was more likely not to have received the
screening test within the recommended time interval than the reference group, and odds ratios
less than one indicated that the subgroup was more likely to have received the screening test
within the recommended interval.
Table 15. Association Between Race and Not Receiving Cancer Screening Tests in Delaware
Race
Fecal Occult
Blood Test
Sigmoidoscopy
or Colonoscopy
Prostate-
Specific
Antigen Test
Digital Rectal
Exam
Mammogram
(Females)
Clinical
Breast Exam
(Females)
White
African American
Reference
1.4 (0.92, 2.1)
Reference
1.3 (0.95, 1.8)
Reference
0.68 (0.39, 1.2)
Reference
0.78 (0.51, 1.2)
Reference
0.83 (0.53, 1.3)
Reference
0.78 (0.55, 1.1)
Source: BRFSS, 2002.
Table 16. Multivariate Model of Predictors for Not Receiving Cancer Screening Tests in Delaware
Fecal Occult
Blood Test
Sigmoidoscopy
or Colonoscopy
Prostate-
Specific Antigen
Test
Digital Rectal
Exam
Mammogram
(Females)
Clinical
Breast Exam
(Females)
Race
White
African American
Reference
1.2 (0.82, 1.9)
Reference
1.1 (0.76, 1.5)
Reference
0.49 (0.24, 1.0)
Reference
0.62 (0.32, 1.0)
Reference
0.93 (0.36, 1.1)
Reference
0.70 (0.46, 1.1)
Age
< 40
40–49
50–64
65–79
80+
NA
NA
Reference
0.77 (0.60, 0.97)
1.0 (0.70, 1.6)
NA
NA
Reference
0.68 (0.55, 0.84)
1.0 (0.73, 1.5)
NA
NA
Reference
0.67 (0.46, 0.98)
0.89 (0.46, 1.7)
NA
Reference
0.29 (0.21, 0.40)
0.25 (0.17, 0.36)
0.38 (0.20, 0.73)
NA
Reference
0.35 (0.24, 0.51)
0.53 (0.36, 0.78)
1.4 (0.85, 2.2)
Reference
1.5 (0.99, 2.2)
1.3 (0.90, 1.9)
2.1 (1.4, 3.0)
5.5 (3.4, 8.9)
Sex
Male
Female
Reference
1.0 (0.83, 1.3)
Reference
1.1 (0.91, 1.4)
NA
NA
NA
NA
NA
NA
NA
NA
Education
< High school
High school graduate
Some college
College graduate
1.2 (0.80, 1.8)
0.97 (0.73, 1.3)
0.85 (0.63, 1.2)
Reference
2.7 (1.9, 3.9)
2.1 (1.6, 2.7)
1.6 (1.2, 2.1)
Reference
1.8 (1.0, 3.2)
0.86 (0.55, 1.3)
0.99 (0.63, 1.6)
Reference
2.3 (1.4, 3.7)
1.3 (0.94, 1.9)
0.94 (0.64, 1.4)
Reference
2.1 (1.2, 3.6)
1.8 (1.2, 2.6)
1.2 (0.75, 1.8)
Reference
4.5 (2.8, 7.4)
2.5 (1.7, 3.7)
2.0 (1.3, 3.0)
Reference
County
New Castle
Kent
Sussex
Reference
0.69 (0.51, 0.93)
0.60 (0.45, 0.78)
Reference
1.0 (0.81, 1.4)
1.1 (0.88, 1.4)
Reference
0.76 (0.48, 1.2)
0.92 (0.60, 1.4)
Reference
0.76 (0.53, 1.1)
0.86 (0.62, 1.2)
Reference
1.0 (0.68, 1.5)
1.2 (0.84, 1.7)
Reference
0.73 (0.53, 1.0)
0.73 (0.54, 1.0)
Health insurance
Yes
No
Reference
1.4 (0.74, 2.7)
Reference
2.5 (1.4, 4.6)
Reference
3.7 (1.6, 8.3)
Reference
2.2 (1.1, 4.3)
Reference
2.6 (1.5, 4.6)
Reference
2.1 (1.4, 3.2)
Personal doctor
Yes
No
Reference
2.5 (1.2, 5.3)
Reference
2.3 (1.3, 4.0)
Reference
3.8 (1.6, 8.6)
Reference
4.0 (2.0, 8.1)
Reference
3.5 (1.9, 6.4)
Reference
1.7 (1.0, 2.8)
Usual source of care
Yes
No
Reference
0.72 (0.42, 1.2)
Reference
0.93 (0.57, 1.5)
Reference
0.85 (0.41, 1.8)
Reference
1.1 (0.59, 1.9)
Reference
1.9 (1.0, 3.5)
Reference
2.2 (1.3, 3.5)
Source: BRFSS, 2002.
* A lack of health insurance or a personal doctor was associated with not receiving screening
exams; lack of a usual source of care appeared to impact only receipt of a clinical breast exam.
* Having less than a high school education was strongly associated with not receiving screening
exams.
* With the exception of clinical breast exams, advancing age was most often associated with an
increasing likelihood of receipt of screening exams.
* There was no association between race, sex or county of residence and the receipt of screening
exams.
3.3.2. Stage at Diagnosis
Stage of disease at site-specific cancer diagnosis was evaluated for the different racial and ethnic
groups in Delaware by examining the proportion of individuals who were diagnosed at each
cancer stage. The variations in stage at diagnosis for female breast, colorectal, and prostate
cancer were examined by county and age at diagnosis. Stage was classified as local, regional, or
distant. Regional and distant were combined to form the category of advanced stage.
3.3.2.1. Female Breast Cancer
Figure 25. Percentage of female breast cancer cases, by stage at diagnosis and race, in
Delaware
Source: DCR, 1998–2002.
* A larger proportion of White women were diagnosed with local disease than African
American women, while more African American women were diagnosed with regional
disease. White and African American women were equally likely to be diagnosed with
distant disease.
Figure 26. Percentage of female breast cancer cases diagnosed at an advanced stage, by
race and county of residence, in Delaware
Source: DCR, 1998–2002.
* African American women residing in all counties in Delaware had a higher percentage of
advanced disease than White women, with no strong evidence of differences depending on
the county of residence at diagnosis.
Figure 27. Percentage of female breast cancer cases diagnosed at an advanced stage, by
race and age at diagnosis, in Delaware
Source: DCR, 1998–2002.
* African American women diagnosed with breast cancer when they were aged 79 or younger
were more likely to be diagnosed with advanced disease than White women.
* The effect of age at diagnosis on the proportion diagnosed with advanced disease may
depend on race. For African American women the proportion with advanced disease
generally decreased with age, while in White women the proportion decreased until age 70,
when it began to increase.
3.3.2.2. Colorectal Cancer
Figure 28. Percentage of colorectal cancer cases, by stage at diagnosis and race, in
Delaware
Source: DCR, 1998–2002.
* African Americans were equally likely to be diagnosed with local disease as Whites. The
data suggest that Whites may be slightly more likely to be diagnosed with regional disease,
and African Americans with distant disease.
Figure 29. Percentage of colorectal cancer cases diagnosed at an advanced stage, by race
and county of residence, in Delaware
Source: DCR, 1998–2002.
* There is no evidence that the proportion of colorectal cancer cases diagnosed at advanced
stage differs between Whites and African Americans.
* The data suggest that for all races the proportion diagnosed with advanced disease was
highest in New Castle County and lowest in Sussex County.
Figure 30. Percentage of colorectal cancer cases diagnosed at an advanced stage, by race
and age at diagnosis, in Delaware
Source: DCR, 1998–2002.
* The proportions of Whites diagnosed with advanced stage disease may decrease with age
until after age 80, when it increases.
* The proportion of African Americans diagnosed with advanced stage disease was not
affected by age at diagnosis.
3.3.2.3. Prostate Cancer
Figure 31. Percentage of prostate cancer cases, by stage at diagnosis and race, in Delaware
Source: DCR, 1998–2002.
* There was minimal difference between Whites and African Americans regarding the stage of
disease at diagnosis.
Figure 32. Percentage of prostate cancer cases diagnosed at an advanced stage, by race
and county of residence, in Delaware
Source: DCR, 1998–2002.
* There was minimal difference in the proportion diagnosed with advanced stage disease, and
it does not appear to differ by county of residence.
Figure 33. Percentage of prostate cancer cases diagnosed at an advanced stage, by race
and age at diagnosis, in Delaware
Source: DCR, 1998–2002.
* Men of both races aged 80 or older at diagnosis were the most likely to be diagnosed with
advanced stage disease.
* There was little difference in the proportion between Whites and African Americans.
3.3.3. Cancer Treatment
Table 17 displays the results of the validation study undertaken to assess the completeness/
accuracy of the treatment-related data resident in the Delaware Cancer Registry; it reports the
number and percentage of cancer cases receiving “standard” treatment (pre-validation study) and
“appropriate” treatment (post-validation study).
Table 17. Number and Percentage of Delaware Breast or Colorectal Cancer Patients
With Local Disease Treated for Cancer in Delaware, by Receipt of Standard / Appropriate
Cancer Treatment
Study
Female
Breast
# (%)
Colorecta
l
# (%)
Pre-validation study
Received standard treatment
Did not receive standard treatment
814 (75.5)
264 (24.5)
3 (4.1)
70 (95.9)
Post-validation study
Received appropriate treatment
Did not receive appropriate treatment
1,001 (93.1)
74 ( 6.9)
63 (91.3)
6 (8.7)
Source: DCR, 1998–2002 (Pre-validation); DCR + source documents (Post-validation)
* The proportion of patients receiving standard/appropriate treatment changed dramatically
between the pre- and post-validation studies: Receipt of appropriate breast cancer treatment
increased from 75.5% of patients to 93.1%; receipt of appropriate colorectal cancer treatment
increased from 4.1% to 91.3%.
Source document review revealed substantial differences between the treatment documented in
patients’ medical records and the treatment captured into the DCR. In the case of breast cancer
treatment, these differences chiefly took the form of incomplete DCR data; e.g., radiation
treatments received post-breast conserving surgery were clearly documented in source records
but were not recorded in DCR files. In the case of colorectal cancer, the very substantial change
in the proportion of patients receiving appropriate treatment was chiefly due to reviewers’ ability
to determine that the surgery performed (i.e., polypectomy v. at least partial colectomy) was
appropriate, given the specific site and stage of cancer reflected in the surgery and pathology
reports.
Table 18 presents the results of an analysis examining the likelihood of an association between
receipt of standard treatment and each of three other variables: treating facility, type of cancer,
and race. The analysis was done on both the pre-validation dataset and the post-validation
dataset.
Table 18. Association Between Receipt of Standard Treatment and Treating Facility,
Cancer Type and Race Among Individuals with Local Cancer and Treated in Delaware
Likelihood of
Receipt of
Standard Treatment
Associated with
Facility
Associated with
Cancer Type
Associated with
Race
Pre-validation study
Statistically significant
p <0.0001
Statistically significant
p <0.0001
Statistically significant
p <0.0007
Post-validation study
Statistically significant
p <0.0001
Not statistically
significant
p = 0.57
Not statistically
significant
p = 0.33
Source: DCR, 1998–2002 (Pre-validation); DCR + source documents (Post-validation)
* Treating facility, cancer type and race were all strongly associated with the likelihood of
receiving standard treatment in the pre-validation study, which relied solely on DCR data.
* In the post-validation analysis, which included source data not captured in the DCR, only
treating facility continued to show a strong association with the likelihood of receiving
appropriate treatment.
3.4. HEALTH POLICY, HEALTH SYSTEM, AND SOCIETAL FACTORS
The impact of determinants of disparities that operate on an individual level has been examined
in earlier sections of this report. However, research has suggested that some of the explanation
for disparities may be the result of societal not individual factors. As we have seen from previous
analyses, socioeconomic status is a significant factor affecting racial/ethnic disparities in the
cancer burden in the United States. Unfortunately, many of the other societal components were
not available in the data sources used. In this section the literature on these societal factors is
briefly reviewed. This review considers two aspects of societal factors: patient and system
barriers to preventive and cancer care. Patient barriers affect the benefit that minorities receive
from the delivery of cancer services, whereas system barriers include factors that determine
inequality in the delivery of the services. The relationship between race and ethnicity may be
even more complex, as outlined in the model used by the National Center on Minority Health
and Health Disparities in its Strategic Research Plan and Budget to Reduce and Ultimately
Eliminate Health Disparities. Several patient barriers affect morbidity and mortality rates among
different racial/ethnic populations. Financial and socioeconomic barriers, including poverty, lack
of health insurance, and underinsurance, greatly influence access to appropriate early detection,
treatment, and palliative care. Several studies have found that African Americans, especially
those without insurance and with a lower household income, are more likely to be diagnosed
with later stage cancer, which contributes to an increased mortality rate. Hiatt et al. found that
the strongest predictors of cancer screening were private health insurance and frequent use of
medical services (33). African Americans have a two-fold increased risk of being diagnosed with
advanced-stage prostate cancer compared with non-Hispanic Whites (34). Roetzheim et al.
(2000) examined the impact of insurance status among colorectal cancer patients in Florida and
found that among non-Medicare patients, those with no health insurance were less likely to
undergo surgery than patients with indemnity insurance, after adjustment for stage at diagnosis.
Uninsured patients and patients enrolled in health maintenance organization (HMO) plans also
had higher mortality rates than patients enrolled in fee-for-service plans.
Physical barriers can also impede a patient’s ability to access proper care. Many patients lack
transportation, are physically disabled, or are too frail to travel to a medical facility. Competing
life demands can become a physical barrier when patients are unable to take time off from a job
to receive needed services, particularly when providers lack convenient service hours.
Other patient barriers result from a patient’s lack of health literacy or inability to assess
information regarding cancer prevention and treatment. In minority communities there is often a
lack of knowledge regarding the risks associated with not participating in recommended
preventative screenings and not maintaining a healthy lifestyle, resulting in decreased screening
rates in these communities. Even when minority communities are educated about cancer health,
recommendations are often not acted on appropriately due to potential embarrassment and
discomfort or to confusion about how to seek the needed care. Language barriers and a lack of
translators prevent many minorities from accessing both information and treatment. The Breast
and Cervical Cancer Intervention Study found low rates of Pap test screening, the key preventive
measure against cervical cancer, among non-English-speaking Latina and Chinese women, a
finding that may be generalized to apply to other immigrant populations (35). Language is not
the only cultural barrier preventing minorities from receiving proper cancer care; a distrust of
conventional medical care, fatalism, and modesty among minority communities also contribute
to low screening rates (8).
Like patient barriers, health system barriers affect cancer morbidity and mortality rates among
minorities. Cancer services are not delivered as a lifetime continuum of care. Many minorities do
not receive recommended cancer screenings, and those who do often receive inconsistent
followup care. African Americans in some areas of the United States have higher Pap test rates
but are still diagnosed in later stages of disease and have higher mortality than Whites. This can
be attributed, in part, to the testing being performed in areas without an infrastructure for
notification and followup of abnormal results (35). Followup care may be substandard among
minority communities, since they may not have access to physicians with adequate training in
adult or pediatric oncology or newer or proven therapies. End-of-life care tends to be worse
among minority patients due to inequalities in pain management and hospice care; patients seen
at outpatient centers that predominantly treat minorities were three times more likely than those
treated elsewhere to have inadequate pain management (36). Studies have also shown lower
usage of hospice care among minority communities, including African Americans, Asians, and
White and non-White Hispanics (8).
Further system barriers stem from failures among Federal, State, and local agencies in
implementing or enforcing policies that address racial/ethnic disparities in cancer treatment and
prevention. Title VI of the U.S. Civil Rights Act of 1964 prohibits discrimination and recipient
practices that have the effect of discrimination on the basis of race, color, and national origin in
programs and activities receiving Federal financial assistance (37). In addition to Title VI,
national standards for culturally and linguistically appropriate services (CLAS) in health care
were published in 2000 by the Department of Health and Human Services’ Office of Minority
Health and adopted in an effort to implement standards of equality in health care for minorities
(38). It is clear, however, that Title VI and the standards set in place in CLAS are not being
upheld to the fullest extent possible, since minorities continue to be inadequately insured and
face unequal access to quality cancer care. National efforts to combat these inequalities include
the National Breast and Cervical Cancer Early Detection Program and the Screen for Life:
National Colorectal Action Campaign, both administered by CDC. These programs are aimed at
providing preventive education and screening for at-risk populations. Specifically, the National
Breast and Cervical Cancer Early Detection Program helps low-income, uninsured, and
underserved women gain access to lifesaving screening programs for early detection of female
breast and cervical cancers, and the Screen for Life: National Colorectal Action Campaign
informs men and women aged 50 years or older about the importance of having regular
colorectal cancer screening tests (39, 40). These programs promote national awareness of the
importance of cancer prevention and early detection.
More can be done at the State level to increase access to cancer care and reduce cancer risks.
Delaware has made progress in passing legislation mandating insurance coverage for annual
mammograms for asymptomatic women aged 40 and over, ensuring that annual Pap tests are
covered in health insurance contracts, and requiring group and individual health insurers, HMOs,
and health service corporations to provide insurance coverage for colorectal cancer screening in
certain situations (41). There are two areas where improvement is possible: 1) insurance
coverage is ensured for only select phases of clinical trials and 2) the Tobacco Excise Tax is still
below the national average. Increasing coverage for clinical trials would give the uninsured
access to cutting-edge medical treatments and inform researchers of the efficacy of the
treatments in a study group that is more representative of the population of cancer patients.
Raising the tobacco excise tax would encourage residents of Delaware to quit smoking due to
increased costs.
Even with the presence of antidiscrimination laws, racial/ethnic discrimination still affects cancer
service. Research shows that minorities receive a lower quality of care when they are in the
health care system, after controlling for social determinants and insurance status. A phone survey
of 3,884 people conducted by the Kaiser Family Foundation in 2000 found that 36 percent of
Hispanics and 35 percent of African Americans (compared with 15 percent of Whites) felt that
they were treated unfairly in the health care system based on their race/ethnicity (42).
Research shows a lack of initiative among health care delivery systems to take on the challenge
of eliminating patient and system barriers due to a high initial cost and lack of incentives (11).
Further research is necessary to determine the best strategies for the Federal, State, and private
sectors to implement in order to jointly address the elimination of cancer disparities.
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APPENDIX A:
SUPPLEMENTAL INFORMATION ON REPORT METHODOLOGY
Table A1. NAACCR Certification of the Delaware Cancer Registry’s 2002 Incidence Data
NAACCR
Registry Certification on Quality, Completeness, and Timeliness of 2002 Data
Summary of Certification Measures
Registry Element
Gold Standard
Silver Standard
Actual
Measure
Measurement
Error Allowed
Standard
Achieved
1. Completeness of case ascertainment
95%
90%
92.2%
1.0%
Silver
2. Completeness of information recorded
* Missing/unknown “age at diagnosis”
* Missing/unknown “sex”
* Missing/unknown “race”
Missing/unknown “state/province &
county”
<=2%
<=2%
<=3%
<=2%
<=3%
<=3%
<=5%
<=3%
0.0%
0.1%
1.2%
0.1%
-0.4%
-0.4%
-0.4%
-0.4%
Gold
Gold
Gold
Gold
3. Death certificate only cases
<=3%
<=5%
1.2%
-0.4%
Gold
4. Duplicate primary cases
<=1 per 1,000
<=2 per 1,000
0.0 per 1,000
-0.4 per 1,000
Gold
5. Passing edits
100%
97%
100%
Not applicable
Gold
6. Timeliness
Data submitted within 24 months of close of accession year
Gold
Certification Status
Silver
Table A2. Number and Percentage of Cancer Cases, by Race/Ethnicity and Cancer Site,
Delaware 1998–2002
Race/Ethnicity
All
Female
Breast
Colorectal
Lung and
Bronchus
Prostate
Total
White
African American
Hispanic
Asian, Pacific
Islanders, American
Indians, and Alaska
Natives
Missing
19,849
16,416 (83)
2,867 (14)
187 (0.9)
169 (0.8)
210 (1.1)
2,792
2,322 (83)
392 (14)
23 (0.8)
33 (1.2)
22 (0.8)
2,212
1,841 (83)
324 (15)
9 (0.4)
20 (0.9)
18 (0.8)
3,070
2,609 (85)
418 (14)
18 (0.6)
19 (0.6)
6 (0.2)
3,134
2,448 (78)
591 (19)
24 (0.8)
16 (0.5)
55 (1.8)
Table A3. Comparison of the Percentage of Individuals in Each Stage of Diagnosis and
Race Group in Delaware and the United States, 1998–2002
Delaware
United States
White
African
American
White
African
American
Female breast cancer
Local
Regional
Distant
Unstaged
67
26
4
4
58
33
4
5
65
29
4
2
53
36
7
4
Colorectal cancer
Local
Regional
Distant
Unstaged
29
47
16
7
29
44
21
6
40
38
17
5
35
35
23
7
Prostate cancer
Local
Regional
Distant
Unstaged
83
8
4
5
85
5
4
6
80
13
4
3
79
12
6
3
Table A4. Description of the SEER Program Codes and Surgical Procedures Used To
Define Standard Treatment for Each of the Cancers Examined
Female Breast
Colorectal
Lung and Bronchus
Prostate
0
No surgery
10-19
Local tumor destruction
20-29
Partial mastectomy
Local tumor
excision
Excision of <1 lobe
Local tumor
excision
30-39
Subcutaneous
mastectomy
Partial colectomy
Partial
pneumonectomy
Subtotal
prostatectomy
40-49
Total mastectomy
Hemi-colectomy
Extended lobe or
bilobectomy
50-59
Modified radical
mastectomy
Total colectomy
Pneumonectomy
Total
prostatectomy
60-69
Radical
mastectomy
Total
proctocolectomy
Extended
pneumonectomy
70-79
Extended radical
mastectomy
30-60 with
contiguous organs
Extended radical
pneumonenctomy
50 with contiguous
organs
80
Mastectomy, NOS
Colectomy, NOS
Resection, NOS
Prostatectomy,
NOS
90
Surgery, NOS
99
Unknown
Cells in blue designate standard treatment, and cells in yellow refer to nonstandard treatment. Cells in
green were defined as standard if individuals also received radiation; if they did not receive radiation,
they were coded as not receiving standard treatment. The cells in gray were considered to be missing
data on surgical procedure.
APPENDIX B:
SUPPLEMENTAL INCIDENCE AND MORTALITY DATA
Table B1. Number of New Cancer Cases and Age-Adjusted Incidence Rates (With
95-Percent Confidence Intervals), by Race in Delaware and the United States, 1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
Delaware
All sites
Female breast
Colorectal
Lung and bronchus
Prostate
16,416
2,322
1,841
2,609
2,448
489.9 (482.5, 497.5)
130.2 (125.0, 135.6)
54.5 (52.1. 57.1)
76.1 (73.2, 79.1)
159.4 (153.2, 165.9)
2,867
392
324
418
591
531.4 (512.3, 551.3)
117.6 (106.5, 129.9)
64.9 (58.2, 72.4)
80.7 (73.3, 88.8)
267.6 (246.9, 290.1)
United States
All sites
Female breast
Colorectal
Lung and bronchus
Prostate
508,532
80,260
55,976
67,118
78,732
489.1 (487.7, 490.4)
143.0 (142.0, 144.0)
53.6 (53.1, 54.0)
65.0 (64.5, 65.4)
173.5 (172.3, 174.7)
55,966
6,362
8,421
11,639
7,907
519.3 (514.9, 523.8)
118.7 (116.1, 121.4)
62.6 (61.1, 64.2)
81.7 (79.9, 83.5)
277.1 (271.9, 282.5)
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates based on
counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based on the
November 2003 submission; and National Center for Health Statistics.
There were 150 cases of cancer diagnosed among Asians and Pacific Islanders, with a rate of
282.6 (240.8, 331.7), and 187 cases of cancer diagnosed among Hispanics, with a rate of 250.4
(217.0, 289.0).
Table B2. Number of Cancer Deaths and Age-Adjusted Mortality Rates (With 95-Percent
Confidence Intervals), by Race in Delaware and the United States, 1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
Delaware
All sites
Female breast
Colorectal
Lung and bronchus
Prostate
7,002
513
676
2,128
328
207.5 (202.6, 212.4)
27.2 (25.0, 29.7)
20.0 (18.6, 21.6)
62.1 (59.5, 64.8)
26.3 (23.5, 29.2)
1,249
115
140
335
102
251.3 (237.8, 265.6)
36.2 (30.1, 43.4)
29.4 (24.9, 34.7)
66.8 (60.0, 74.3)
64.9 (53.5, 78.8)
United States
All sites
Female breast
Colorectal
Lung and bronchus
Prostate
2,389,534
176,758
245,335
682,251
127,744
195.3 (195.0, 195.5)
25.9 (25.8, 26.0)
20.0 (19.9, 20.0)
55.8 (55.6, 55.9)
27.7 (27.6, 27.9)
309,865
27,078
33,963
80,407
26,549
248.1 (247.3, 249.0)
34.7 (34.3, 35.1)
27.9 (27.6, 28.2)
64.1 (63.6, 64.5)
68.1 (67.3, 69.0)
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates based
on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based on
the November 2003 submission; and National Center for Health Statistics.
In Delaware, there were 42 deaths from cancer among Asians and Pacific Islanders, with a rate
of 104.7 (77.4, 141.6), and there were 80 deaths from cancer among Hispanics, with a rate of
149.9 (120.4, 186.6).
Table B3. Number of New Cancer Cases and Age-Adjusted Incidence Rates (With
95-Percent Confidence Intervals), by Race and Sex in Delaware and the United States,
1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
Delaware
All sites
Male
Female
Colorectal
Male
Female
Lung and bronchus
Male
Female
8,524
7,892
932
909
1,467
1,142
570.3 (558.3, 582.5)
433.9 (424.4, 443.6)
63.9 (59.9, 68.2)
47.0 (44.1, 50.2)
97.1 (92.3, 102.2)
60.3 (56.9, 63.8)
1,522
1,343
149
174
234
194
679.3 (646.0, 714.3)
426.3 (404.1, 449.7)
71.3 (60.7, 83.7)
59.6 (51.3, 69.1)
108.2 (95.2, 123.0)
65.6 (57.0, 75.5)
United States
All sites
Male
Female
Colorectal
Male
Female
Lung and bronchus
Male
Female
259,777
248,755
28,068
27,908
36,430
30,688
569.7 (567.5, 571.9)
435.6 (433.9, 437.3)
62.9 (62.2, 63.6)
46.4 (45.8, 46.9)
81.3 (80.4, 82.1)
53.4 (52.8, 54.0)
30,216
25,750
2,995
3,367
4,957
3,464
692.5 (684.3, 700.9)
404.1 (399.1, 409.2)
72.9 (70.2, 75.8)
56.2 (54.3, 58.1)
117.4 (114.0, 121.0)
57.6 (55.7, 59.6)
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
Table B4. Number of Cancer Deaths and Age-Adjusted Mortality Rates (With 95-Percent
Confidence Intervals), by Race and Sex in Delaware and the United States, 1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
Delaware
All sites
Male
Female
Colorectal
Male
Female
Lung and bronchus
Male
Female
3,615
3,387
349
327
1,220
908
253.9 (245.8, 262.3)
176.4 (170.6, 182.5)
24.8 (22.3, 27.5)
16.6 (14.9, 18.5)
82.5 (78.0, 87.2)
47.2 (44.2, 50.4)
634
615
64
76
198
137
329.8 (305.1, 356.5)
206.2 (190.5, 223.2)
34.0 (26.6, 43.4)
26.3 (21.0, 32.9)
97.4 (84.7, 111.9)
46.8 (39.6, 55.4)
United States
All sites
Male
Female
Colorectal
Male
Female
Lung and bronchus
Male
Female
1,236,918
1,152,616
122,299
123,036
393,149
289,102
242.5 (242.0, 242.9)
164.5 (164.2, 164.8)
24.3 (24.1, 24.4)
16.8 (16.7, 16.9)
75.2 (75.0, 75.5)
41.8 (41.7, 42.0)
163,486
146,379
16,175
17,788
50,738
29,669
339.4 (337.6, 341.1)
194.3 (193.3, 195.3)
34.0 (33.4, 34.5)
24.1 (23.7, 24.4)
101.3 (100.3, 102.2)
39.9 (39.4, 40.3)
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
There were 41 deaths from cancer in Hispanic men, with a rate of 196.7, and 39 deaths from
cancer among Hispanic women, with a rate of 121.9.
Table B5. Number of New Cancer Cases and Age-Adjusted Incidence Rates (With
95-Percent Confidence Intervals), by Race and Age in Delaware, 1998–2002
White
African American
Age (Years)
Number
Rate (95% CI)
Number
Rate (95% CI)
All sites
20–39
40–49
50–64
65–79
80+
826
1,257
4,532
7,307
2,494
55.1 (51.5, 59.0)
280.1 (265.0, 296.0)
922.5 (896.1, 949.8)
2,185.3 (2135.8, 2236.0)
2,308.1 (2219.3, 2400.5)
238
361
984
980
304
47.6 (41.9, 54.1)
327.2 (295.2, 362.8)
1,065.1 (1000.6, 1133.8)
2,216.1 (2081.6, 2359.3)
2,450.0 (2189.5, 2741.5)
Female breast
20–39
40–49
50–64
65–79
80+
99
340
772
824
287
13.3 (10.9, 16.2)
149.8 (134.7, 166.6)
303.2 (282.5, 325.3)
449.0 (419.3, 480.7)
401.4 (357.5, 450.6)
46
112
122
80
32
18.0 (13.5, 24.1)
185.3 (154.0, 223.0)
244.8 (205.0, 292.3)
312.6 (251.1, 389.2)
375.8 (265.7, 531.4)
Colorectal
20–39
40–49
50–64
65–79
80+
30
94
391
875
451
2.0 (1.4, 2.9)
20.9 (17.1, 25.6)
79.6 (72.1, 87.9)
261.7 (244.9, 279.6)
417.4 (380.6, 457.7)
< 25
33
87
123
66
NA
29.9 (21.3, 42.1)
94.2 (76.3, 116.2)
278.1 (233.1, 331.9)
531.9 (417.9, 677.0)
Lung and bronchus
20–39
40–49
50–64
65–79
80+
36
109
714
1,399
351
2.4 (1.7, 3.3)
24.3 (20.1, 29.3)
145.3 (135.1, 156.4)
418.4 (397.0, 440.9)
324.8 (292.6, 360.7)
< 25
40
161
173
39
NA
36.3 (26.6, 49.4)
174.3 (149.3, 203.4)
391.2 (337.0, 454.1)
314.3 (229.6, 430.2)
Prostate
20–39
40–49
50–64
65–79
80+
< 25
36
775
1,365
271
NA
16.2 (11.7, 22.5)
327.5 (305.3, 351.4)
904.9 (858.2, 954.2)
741.5 (658.3, 835.2)
< 25
< 25
270
253
41
NA
NA
634.6 (563.2, 715.0)
1,358.0 (1200.6, 1536.1)
1,053.4 (775.7, 1430.7)
NA = Rates are based on counts too small to be displayed.
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
Table B6. Number of Cancer Deaths and Age-Adjusted Mortality Rates (With 95-Percent
Confidence Intervals), by Race and Age in Delaware, 1998–2002
White
African American
Age (Years)
Number
Rate (95% CI)
Number
Rate (95% CI)
All sites
20–39
40–49
50–64
65–79
80+
142
303
1,450
3,302
1,805
9.5 (8.0, 11.2)
67.5 (60.3, 75.6)
295.2 (280.4, 310.8)
987.5 (954.4, 1021.8)
1,670.5 (1,595.2, 1,749.4)
47
114
340
515
233
9.4 (7.1, 12.5)
103.3 (86.0, 124.2)
368.0 (330.9, 409.3)
1,164.6 (1,068.2, 1,269.6)
1,877.8 (1,651.5, 2,135.1)
Female breast
20–39
40–49
50–64
65–79
80+
< 25
39
118
196
147
NA
17.2 (12.6, 23.5)
46.3 (38.7, 55.5)
106.8 (92.8, 122.8)
205.6 (174.9, 241.6)
< 25
25
41
29
< 25
NA
41.4 (28.0, 61.2)
82.3 (60.6, 111.7)
113.3 (78.8, 163.1)
NA
Colorectal
20–39
40–49
50–64
65–79
80+
< 25
< 25
121
323
206
NA
NA
24.6 (20.6, 29.4)
96.6 (86.6, 107.7)
190.6 (166.3, 218.5)
< 25
< 25
37
59
32
NA
NA
40.1 (29.0, 55.3)
133.4 (103.4, 172.2)
257.9 (182.4, 364.7)
Lung and
bronchus
20–39
40–49
50–64
65–79
80+
< 25
67
519
1,142
384
NA
14.9 (11.8, 19.0)
105.6 (96.9, 115.1)
341.5 (322.3, 361.9)
355.4 (321.6, 392.8)
< 25
25
112
152
44
NA
22.7 (15.3, 33.5)
121.2 (100.7, 145.9)
343.7 (293.2, 403.0)
354.6 (263.9, 476.5)
Prostate
20–39
40–49
50–64
65–79
80+
< 25
< 25
< 25
150
157
NA
NA
NA
99.4 (84.7, 116.7)
429.6 (367.4, 502.3)
<25
<25
<25
56
36
NA
NA
NA
300.6 (231.3, 390.6)
925.0 (667.2, 1,282.3)
NA = Rates are based on counts too small to be displayed.
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
Table B7. Number of New Cancer Cases and Age-Adjusted Incidence Rates (With
95-Percent Confidence Intervals), by Race and County of Residence in Delaware,
1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
All sites
Kent
New Castle
Sussex
2,286
9,661
4,461
467.4 (448.6, 487.0)
500.1 (490.2, 510.2)
481.3 (467.4, 495.6)
439
1,957
470
463.9 (422.5, 509.4)
557.2 (533.1, 582.5)
501.4 (458.0, 548.8)
Female breast
Kent
New Castle
Sussex
331
1,397
573
125.4 (112.6, 139.6)
133.2 (126.4, 140.4)
120.8 (111.3, 131.1)
55
284
53
98.8 (75.8, 128.7)
128.1 (114.1, 143.9)
96.6 (73.8, 126.4)
Colorectal
Kent
New Castle
Sussex
291
1,074
517
60.2 (53.6, 67.5)
54.6 (50.4, 58.6)
54.5 (50.0, 59.4)
68
210
46
78.1 (61.6, 99.1)
66.4 (58.0, 76.0)
51.0 (38.2, 68.1)
Lung and bronchus
Kent
New Castle
Sussex
422
1,394
793
85.4 (77.6, 93.9)
71.7 (68.0, 75.5)
80.5 (75.1, 86.3)
60
283
75
66.2 (51.4, 85.2)
83.8 (74.6, 94.1)
81.5 (65.0, 102.1)
Prostate
Kent
New Castle
Sussex
286
1,542
620
126.1 (112.3, 141.6)
182.5 (173.6, 191.9)
132.8 (122.7, 143.6)
91
411
88
210.4 (171.4, 258.4)
297.2 (269.8, 327.4)
227.0 (184.2, 279.8)
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
Table B8. Number of Cancer Deaths and Age-Adjusted Mortality Rates (With 95-Percent
Confidence Intervals), by Race and County of Residence in Delaware, 1998–2002
White
African American
Number
Rate (95% CI)
Number
Rate (95% CI)
All sites
Kent
New Castle
Sussex
1,048
4,055
1,899
215.7 (203.0, 229.2)
208.9 (202.6, 215.4)
202.4 (193.5, 211.8)
214
806
229
246.7 (215.8, 282.1)
252.1 (235.3, 270.1)
251.1 (220.6, 285.8)
Female breast
Kent
New Castle
Sussex
76
315
122
28.0 (22.3, 35.0)
28.2 (25.2, 31.5)
24.9 (20.8, 29.7)
< 25
76
25
NA
36.8 (29.4, 46.1)
45.9 (31.0, 67.9)
Colorectal
Kent
New Castle
Sussex
81
401
194
16.8 (13.5, 20.9)
20.7 (18.7, 22.8)
20.7 (18.0, 23.8)
26
86
28
31.3 (21.3, 46.0)
28.9 (23.4, 35.7)
31.1 (21.5, 45.1)
Lung and bronchus
Kent
New Castle
Sussex
363
1,148
617
73.8 (66.6, 81.8)
58.9 (55.6, 62.4)
63.2 (58.4, 68.4)
51
219
65
57.0 (43.3, 75.0)
67.8 (59.4, 77.4)
71.0 (55.7, 90.5)
Prostate
Kent
New Castle
Sussex
37
199
92
20.9 (15.2, 28.9)
28.3 (24.6, 32.5)
24.4 (19.9, 30.0)
< 25
59
< 25
NA
66.3 (41.6, 72.8)
NA
NA = Rates are based on counts too small to be displayed.
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard million population; rates
based on counts of fewer than 25 are suppressed.
Sources: Delaware Department of Health, Delaware Cancer Registry, 2002; SEER Program, based
on the November 2003 submission; and National Center for Health Statistics.
Table B9. Rate Ratios and Rate Difference Measuring Disparities in Five-Year Average
Cancer Incidence Rates in Three Time Periods Between 1980 and 2002
1980–1984
1990–1994
1998–2002
Rate
Ratio
Rate
Difference
Rate
Ratio
Rate
Difference
Rate
Ratio
Rate
Difference
All sites
Male
Female
1.3
1.0
127.3
14.8
1.4
1.0
253.2
4.3
1.2
1.0
93.9
-8.2
Female breast
0.89
-11.6
0.90
-14.4
0.89
-14.1
Colorectal
Male
Female
0.7
0.8
-26.4
-11.9
1.0
1.1
0.9
6.8
1.1
1.3
8.4
12.7
Lung and bronchus
Male
Female
1.5
1.3
61.7
13.0
1.6
1.1
67.0
8.8
1.1
1.0
10.7
0.1
Prostate
2.0
73.5
1.7
137
1.6
100.7
Table B10. Rate Ratios and Rate Difference Measuring Disparities in Five-Year Average
Cancer Mortality Rates in Three Time Periods Between 1980 and 2002
1980–1984
1990–1994
1998–2002
Rate
Ratio
Rate
Difference
Rate
Ratio
Rate
Difference
Rate
Ratio
Rate
Difference
All sites
Male
Female
1.5
1.3
139.4
47.7
1.6
1.3
184.7
56.6
1.3
1.2
75.9
30.3
Female breast
1.0
1.6
1.0
1.5
1.3
9.0
Colorectal
Male
Female
1.3
1.0
10.2
-0.8
1.1
1.4
2.6
8.9
1.4
1.5
8.8
9.1
Lung and bronchus
Male
Female
1.5
1.6
47.2
17.9
1.6
1.2
60.5
10.3
1.2
1.0
16.7
1.0
Prostate
2.2
40.2
2.5
56.2
2.4
37.7
APPENDIX C:
SUPPLEMENTAL BRFSS INFORMATION
Table C1. Wording of the BRFSS Questions for Each of the Variables Used in This
Analysis
Demographic Variables
What county do you live in?
Kent
Sussex
New Castle
Don’t know/not sure
Refused
What is your age?
Indicate sex of respondent. (Ask only if necessary)
Male
Female
Are you Hispanic or Latino?
Yes
No
Don’t know/not sure
Refused
Which one of the following groups would you say best represents your race?
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian, Alaska Native
Other (specify) _____________________
Don’t know/not sure
Refused
What is the highest grade or year of school you completed? (Read as necessary)
Never attended school or only attended kindergarten
Grades 1 through 8 (elementary school)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 year to 3 years (some college or technical school)
College 4 years or more (college graduate)
Refused
Is your annual household income from all sources:
01 Less than $25,000 (If "no," skip to 5, if "yes," ask 2)
02 Less than $20,000 (If "no," code 1, if "yes," ask 3)
03 Less than $15,000 (If "no," code 2, if "yes," ask 4)
04 Less than $10,000 (If "no," code 2, if “yes” code 4)
05 Less than $35,000 (If "no," ask 6, if “yes” code 5)
06 Less than $50,000 (If "no," ask 7, if “yes” code 6)
07 Less than $75,000 (If "no," code 8, if “yes” code 7)
08 $75,000 or more
77 Don’t remember / Don’t know
99 Refused
Access to Health Care Variables
Do you have any kind of health care coverage, including health insurance, prepaid plans such as
HMOs, or government plans such as Medicare?
Yes
No
Don’t know/not sure
Refused
Do you have one person you think of as your personal doctor or health care provider?
Yes, only one
Yes, more than one
No
Don’t know/not sure
Refused
In the year prior to your cancer diagnosis, when you were sick or needed advice about your
health, to which one of the following places did you usually go?
A doctor’s office
A public health clinic or community health center
A hospital outpatient department
A hospital emergency room
Urgent care center
Some other kind of place (specify) _______________
No usual place
Don’t remember / Don’t know
Refused
Modifiable Risk Factor Variables
When you are at work, which of the following best describes what you do?
Mostly sitting or standing
Mostly walking
Mostly heavy labor or physically demanding work
Don’t know/not sure
Refused
During the past month, other than your regular job, did you participate in any physical activities
or exercise, such as running, calisthenics, golf, gardening, or walking for exercise?
Yes
No
Don’t know/not sure
Refused
Have you smoked at least 100 cigarettes in your entire life?
Yes
No
Don’t know/not sure
Refused
Do you now smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all
Refused
About how much do you weigh without shoes?
__ __ __ Weight in pounds
7 7 7 Don’t know/not sure
9 9 9 Refused
About how tall are you without shoes?
__/__ __ Height in ft/inches
7 7 7 Don’t know/not sure
9 9 9 Refused
The number of servings of fruit and vegetables was calculated by asking respondents each of the
following questions individually using the response categories below.
How often do you drink fruit juices such as orange, grapefruit, or tomato?
Not counting juice, how often do you eat fruit?
How often do you eat green salad?
How often do you eat potatoes, not including French fries, fried potatoes, or potato chips?
How often do you eat carrots?
Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
1 __ __ per day
2 __ __ per week
3 __ __ per month
4 __ __ per year
5 __ __ never
7 7 7 Don’t know/not sure
9 9 9 Refused
A drink of alcohol is one 12 oz. can or bottle of beer, one glass of wine, one 12 oz. can or
bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past 30 days, how many days
per week or per month did you have at least 1 drink of any alcoholic beverage?
__ __ Days per week (specify number of days)
__ __ Days in 30 prior to diagnosis (specify number of days)
No drinks in past 30 days
Don’t know/not sure
Refused
On the days when you drank, about how many drinks did you drink on the average?
__ __ Number of drinks
Don’t know/not sure
Refused
Screening Test Variables
The questions for each of the six screening tests were worded similarly. First the respondent was
asked if they had ever received the test then when they had last received the test. The explanation
for each test and the response categories are listed below.
A blood stool test is a test that may use a special kit at home to determine whether the stool
contains blood. Have you ever had this test with a home kit?
Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the
bowel for signs of cancer or other health problems. Have you ever had either of these exams? A
prostate-specific antigen test, also called a PSA test, is a blood test used to check men for
prostate cancer. Have you ever had a PSA test?
A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a
gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you
ever had a digital rectal exam?
A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for
lumps. Have you ever had a clinical breast exam?
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a
mammogram?
Yes
No
Don’t know/not sure
Refused
How long has it been since you had your last blood stool test using a home kit?
How long has it been since you had your last sigmoidoscopy or colonoscopy?
How long has it been since you had your last PSA test?
How long has it been since you had your last digital rectal exam?
How long has it been since you had your last mammogram?
How long had it been since your last clinical breast exam?
Within the past year (any time less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 5 years (2 years but less than 5 years ago)
5 or more years ago
Don’t know/not sure
Refused
Table C2. Number of Individuals With Valid Data Who Were Included in the Denominator
for Each Variable Analyzed, by Race/Ethnicity in Delaware and the United States
Delaware
United States
White
African
American
Hispanic
White
African
American
Hispanic
Health insurance
3,228
508
118
192,113
19,075
18,088
Personal doctor
3,230
510
119
192,194
19,087
18,111
Usual source of care
3,141
496
104
189,304
18,704
17,606
Exercise
3,232
510
120
192,459
19,127
18,147
Smoking
3,226
507
120
192,052
19,061
18,110
Obesity
3,075
476
110
184,312
18,075
16,795
Diet (fewer than five
servings of fruits and
vegetables a day)
3,232
510
120
190,522
18,830
17,769
Alcohol intake
3,214
506
114
190,738
18,826
17,849
Fecal occult blood test
1,612
159
26*
91,400
6,824
5,614
Sigmoidoscopy
1,615
161
26*
91,035
6,714
5,612
Prostate-specific
antigen test
592
65
11*
33,641
2,304
2,091
Digital rectal exam
886
95
18*
51,216
3,724
3,448
Mammogram (females)
1,362
169
31*
78,214
6,846
5,531
Clinical breast exam
(females)
1,925
325
70
111,676
12,069
10,610
* We did not examine the prevalence of screening tests among Hispanics because the denominator in
Delaware was less than our minimum of 50.
The Delaware Department of Health and Social Services, Division of Public Health
acknowledges ORC MacroSM’s analytic contributions to this report,
performed under contract to the Division.
QRC DIVISION OF MACRO INTERNATIONAL INC.
7315 WISCONSIN AVENUE • SUITE 400W • BETHESDA, MD 20814
Document Control Number: 35-05-20/06/07/01